Guardianship Questionnaire - Law Offices of Rozsa Gyene

SECTION 1: PETITIONER INFORMATION

This is the person requesting to be appointed as guardian.

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Date of Birth

Relationship to Minor *

Are you requesting to be appointed as: *

Guardian of the Person (physical custody)

Guardian of the Estate (financial matters)

Have you ever been convicted of a crime?

Yes

No

SECTION 2: MINOR CHILDREN INFORMATION

List all minor children for whom guardianship is being requested.

SECTION 3: PARENTS' INFORMATION

Mother's Information

Mother's First Name

Mother's Last Name

Mother's Status *

Father's Information

Father's First Name

Father's Last Name

Father's Status *

SECTION 4: REASONS FOR GUARDIANSHIP

The court needs to understand why the parents cannot care for the child(ren).

Please provide detailed explanation: *

Where is/are the child(ren) currently living? *

How long has/have the child(ren) been with you?

SECTION 5: INDIAN CHILD WELFARE ACT (ICWA)

Federal law provides special protections for Native American children. This information is required.

Is the child or either parent a member or eligible for membership in a Native American tribe? *

Yes

No

Unknown

SECTION 6: OTHER INTERESTED PERSONS

List all persons who have an interest in this guardianship (grandparents, siblings, other relatives, etc.)

SECTION 7: CHILD'S ESTATE

Complete if the child has assets requiring management (inheritance, lawsuit settlement, etc.)

Does the child have any assets or income? *

Yes

No

SECTION 8: VISITATION

Should the parents have visitation rights? *

Yes

No

Yes, but supervised only

SECTION 9: EDUCATION AND MEDICAL INFORMATION

School Information

Current School Name:

Grade Level:

School District:

Does the child have an IEP or 504 Plan?

Yes, IEP

Yes, 504 Plan

No

Medical Information

Primary Doctor/Pediatrician:

Doctor's Phone:

Health Insurance Provider:

Any medical conditions or special needs:

Current medications:

SECTION 10: TYPE OF GUARDIANSHIP

What type of guardianship are you seeking? *

Permanent Guardianship

Temporary Guardianship (90 days or less)

Emergency Guardianship (immediate danger)

If temporary, expected end date:

Is reunification with parents expected?

SECTION 11: COURT INFORMATION

Which county court will you file in? *

Are there any existing court cases involving this child?

Yes

No

SECTION 12: ADDITIONAL INFORMATION

Are there any special circumstances the court should know about?

Any special requests for the court?

Do you need attorney representation?