Month*

Year*

Recruiter*

Guardian Name (G/C)

G/C Name*

First Last

Is This New?*

Yes
No

G/C Address*

Street Address City State ZIP Code

Is This New?*

Yes
No

Email*

Is This New?*

Yes
No

Phone*

Is This New?*

Yes
No

Ward Name (W/C)

W/C Name*

First Last

Provider/Facility/Address:*

Street Address City State ZIP Code

Is This New?*

Yes
No

Personal Involvement With Individual Served:

Number

Number of visits with W/C

(If None, please explain)

Approximate number of phone calls and/or written communications with or regarding individual

Approximate hours per month devoted to guardianship or conservatorship responsibilities

Advocacy and Protective Services Provided

Residential Supports and Services*

Community Living with I/DD support
Community Living with Behavioral Health support
Assisted Living
Nursing Facility
State Institution
Medical Hospital
Homeless
Other

Managed Care Organization/MCO-Insurance*

Aetna
Sunflower
United
None

MCO Care Coordinator

Name

First Last

Phone

Email

Case Manager or Social Worker

Name

First Last

Phone

Email

Are current services:*

Meeting the needs
Changes needed

If so, what changes?

Changes observed in medical, physical, or mental health of individual served:*

Yes
No

Problems relating to guardianship:*

Yes
No

If yes, please explain

Joyous or noteworthy events with individual served:

Financial Information

Please indicate:*

Conservator
Guardian with Financial Authority to $10,000
Not Conservator

Who serves as payee?*

Guardian or Conservator
A Payee Program
Service Provider

Payee Program Name

Service Provider Name

Income Benefit Source(s)

Social Security $

VA Benefit $

Railroad Benefits $

Pension $

Earned Income $

Earned Income Source

Bank

Checking Account Balance $

Savings Account Balance $

Funeral/Burial Fund Approximate Value $*

(enter '0' if none)

Special Needs Trust Approximate Value $

(enter '0' if none)

Annual Court Reports filed with the court*

Yes
No

Copy to KGP*

Yes
No

Notes to KGP

A copy of this form will be emailed to you soon after you hit the submit button

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Monthly Report Forms