Confidential Guardianship Questionnaire And Authorization For Release Of Information {SB-18074}

Local Court Form (Rev. 6-28-2016) SB18074 CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION Page 1 of 7 Probate Code 247 1513 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY NAME: STATE BAR NUMBER: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: TELEPHONE NO: ATTORNEY FOR (Name) : FAX NO. (Optional) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO STREET ADDRESS: CITY AND ZIP CODE: BRANCH NAME: GUARDIANSHIP OF THE PERSON ESTATE ( Name) CONFIDENTIAL GUARDIANSHIP QUESTI O NNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION (Probate Code Section 1 5 13) CASE NUMBER: NOTICE TO PROPOSED GUARDIAN OR APPLICANT AND RELEASE OF INFORMATION Each proposed guardian must complete a separate questionnaire. Please be advised, the information provided on this questionnaire will be used to investigation and relationship histories will be fully reported to the court. Re: Guardianship of (name): (name):(name):(name):(name): I give the authority to release any information in its files to Such information may include, but is not limited to, school records, medical records, employment records, and psychological records. T utilizes this information to complete its required investigation in connection with my petition for guardianship of a minor child. I have read and understand the above conditions and agree to them. PRINT NAME OF PROPOSED GUARDIAN OR APPLICANT SIGNATURE OF PROPOSED GUARDIAN OR APPLICANT Date American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form (Rev. 6-28-2016) SB18074 CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION Page 2 of 7 Probate Code 247 1513 Relative (relationship) Non-Relative P ROPOSED GUARDIAN INFORMATION Proposed Guardian : Last First Middle Maiden Name Phone numbers Home : Work : Cell : Address : City : Zip : Place of Birth : Date of Birth : Social Security Number : : Race or Ethnicity : Will you or anyone else in the home require an interpreter? Yes No Language : DESCRIBE YOUR HOME Single Family Home Apartment How long at present address? Rent Own Monthly mortgage payment or rent? $ No. of bedrooms : Will the minor (s) have their own room? Yes No If shared, with whom? Name: Age: Do you have any guns or other weapons stored on the property? Yes No If yes, what type of weapon(s)? Where and how are they stored? Who cares for the minor(s) if adults are employed outside of the home? O THER CHILDREN LIVING IN YOUR HOME UNDER THE AGE OF 18 ( ATTACH ADDITIONAL PAGE IF NECESSARY) Name Relationship to you Date of Birth Place of Birth Grade Level Developmental Disabilities O THER ADULTS LIVING IN YOUR HOME OVER THE AGE OF 18 ( I NCLUDING YOUR SPOUSE ) Name Social Security Number Date of Birth Relationship to you Child Protective Services History ( Yes/No ) Criminal History ( Yes/No ) Does any adult in the home have any problem(s) that could affect the minor (s) , such as a history of child abuse/molest ation , violent behavior, or an alcohol or drug problem? Yes No If yes, explain : American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form (Rev. 6-28-2016) SB18074 CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION Page 3 of 7 Probate Code 247 1513 Have the police ever been to your home? Yes No I f yes, explain when and why (attach additional page if necessary): EMPLOYMENT / INCOME Are you employed? Yes No Name of Employer : Telephone Number: Address of Employer: Length of Employment: Job Title: Last Grade Completed and Special Training: Gross Monthly Income: Income from other sources (retirement, SSI, etc.): YOUR HEALTH CONDITION ( List any prior and/or current physical or mental health problems ) Present health status: Good Fair Poor If Fair or Poor, please explain: Have you ever been treated for or do you now have a physical impairment (e.g. hearing loss)? Yes No If yes, explain in detail , including medications, h ospitalizations , and therapy/counseling (when and where): What, if any medications are you currently taking and what are they are for ? Do you have a history of mental health issue s / impairment s ? Yes No If yes, explain : Have you ever been in counseling? Yes No If yes, when? If yes, what was /is the reason? Drugs Alcohol Grief Domestic Violence Other Explain: CRIMINAL BACKGROUND Were you ever arrested for an offense other than a minor traffic violation? Yes No If yes, give date, place and details of offense (a ttach additional page if necessary ) : Have you had previous involvement with Child Protective Services? Yes No If yes, explain the circumstances in detail and include dates and name of County or Sta te where involvement occurred (attach an additional page if necessary): Are you currently on Probation? Yes No If yes, explain: Are you currently on Parole? Yes No If yes, explain: American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form (Rev. 6-28-2016) SB18074 CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION Page 4 of 7 Probate Code 247 1513 MARRIAGES Indicate if you are : Married Widowed Single Separated Divorced Registered Domestic Partner Date of most recent marriage: Number of children from this marriage: Ages of c hildren: Previous marriages: Name of former spouse s : How were previous marriages terminated (i.e., divorce or death) ? Number of children from previous marriage s : Ages of c hildren: SPOUSE INFORMATION (Complete only if spouse is not a proposed guardian and is, therefore, not required to complete a separate questionnaire) Full name: Maiden name (if applicable): Aliases: Language(s) spoken ( including sign language): Race/Ethnicity: Age: Date of Birth: Place of Birth: Social Security Number: Telephone Number ( TDD): Mobile Phone Number: Employer Name: Employer Phone Number: Employer Address: Job Title: Present health status: Good Fair Poor Does your spouse take any medication? Yes No Does your spouse have any special health problems? Yes No Does your spouse have any mental/emotional problems? Yes No Has your spouse ever used drugs or alcohol? Yes No Have charges ever been filed against your spouse for crimes other than minor traffic citations? Yes No Is your spouse on parole or probation? Yes No Phone Number: Has your spouse had previous involvement with Child Protective Services? Yes No I NFORMATION ABOUT THE MINOR(S) N EEDING GUARDIANSHIP ( ATTACH ADDITIONAL PAGE IF NECESSARY) Minor 1 Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner : Name of school: Telephone: Grade Level: Name of physician caring for minor : Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs: American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form (Rev. 6-28-2016) SB18074 CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND AUTHORIZATION FOR RELEASE OF INFORMATION Page 5 of 7 Probate Code 247 1513 How do you plan to meet the minor Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor ? Yes No Date of the order: Case Number: Where did the proceeding take place? County : St ate: Minor 2 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Name of physician caring for minor : Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs: How do you plan to meet the minor Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor ? Yes No Date of the order: Case Number: Where did the proceeding take place? County: State: Minor 3 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Name of physician caring for minor : Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs: How do you plan to meet the mino