Living Our Mission for More than 70 Years

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513.868.3210
Office Number

888.597.2751
Toll Free Number

Guardianship Application

The information that you provide in this application will be used for the sole purpose of requesting enrolling in a program and/or service offered by our organization. All applications will be reviewed and used to determine eligibility for programs and/or services.

Fax: 513-868-3249

Please note: The information that you provide in this application will be kept confidential within the organization.

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  • Income SourceAmount ($) 
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  • Support System (Include family, friends, neighbors, other contacts) Family must be contacted about Guardianship referral before sending referral to LifeSpan.
  • NameRelationship to ClientAddressPhoneContacted in Regards to Guardianship 
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  • Expert Evaluations will only be accepted by the Probate Court if they are typed.
  • NameSpecialtyPhone 
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  • Specific DiagnosisCurrent Medications 
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  • Functional Limitations:

  • NamePhoneService Provided 
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  • Please attach copies of which is appropriate for client:
  • This field is for validation purposes and should be left unchanged.