Washington State Courts - Guardian Portal

Guardianship Help Resources
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(360) 704-1925 Helpline

Contact Information
Stacey Johnson
Office of Guardianship and Elder Services
Washington State Administrative Office of the Courts
1112 Quince St. SE (Bldg.1)
PO BOX 41170
Olympia, WA 98504-1170
Phone: (360) 705-5302
Fax: (360) 956-5700
guardianshipprogram@courts.wa.gov

Office of Public Guardianship Referral Form

For questions or concerns about the referral form, please contact us at OPG@courts.wa.gov.

	* Required Field
Verification of Referral
Referral Date:	*
Superior Court Case Number (if applicable):

Information of Respondent (individual for whom appointment of a guardian/conservator or DPOA is sought)
Respondent First Name:	*
Respondent Middle Name:
Respondent Last Name:	*
County of Residence:	*


Submitter Information
First Name:	*
Middle Name:
Last Name:	*
Phone:	* Format: XXX-XXX-XXXX
Email:	*
Relationship to Respondent:	*


Court Visitor Information (if applicable)
Court Visitor First Name:
Court Visitor Middle Name:
Court Visitor Last Name:
Court Visitor Phone:	Format: XXX-XXX-XXXX
Court Visitor Email:


Current Living Arrangement of Respondent: *
Homeless Medical Hospital Private Residence with Supported Living Private Residence without Supported Living Adult Family Home (AFH) Skilled Nursing Facility (SNF) Eastern State Hospital Western State Hospital Other DSHS Facility: Other:


Program Eligibility Requirements
The following conditions are true for the Respondent being referred (check all that apply):
	Is aged 18 years or older
	Verification Document/Method: *
	Income does not exceed 200 percent of the federal poverty level (for 2025, $31,300.00 annually or $2,608.33 monthly) OR 400 percent for individuals admitted to an acute care hospital, psychiatric hospital, or state psychiatric hospital (for 2025, $62,600.00 annually or $5,216.67 monthly). This number may change each calendar year and eligibility would change accordingly. Please provide monthly income: * Please provide income sources: (check all that apply) Supplemental Security Income (SSI) Social Security Disability Insurance (SSDI) Social Security Retirement Retirement/Pension Other:
	Verification Document/Method: *
	Is receiving long-term care (LTC) services through the Washington State Department of Social and Health Services (DSHS)
	Verification Document/Method: *
	Is receiving Medicaid/Medicare benefits (not a program eligibility requirement)

Please attach a copy of the Document/Method used for verification of long-term care
	Verification Document/Method: (PDF form only)

	I verify that no family or friends are willing and able to serve and I have completed a Guardian/Conservator Search Form.

Program Priority Criteria

The following conditions are true for the Respondent being referred (check all that apply):
	Indigent/Homeless
	At significant risk of harm from abuse, exploitation, abandonment, neglect or self-neglect. This determination is based on what information? *
	In imminent danger of loss or significant reduction in public services that are necessary to live successfully in the most integrated and least restrictive environment that is appropriate for a specific individual. This determination is based on what information? *

Please indicate what type of decision-making support the Respondent needs: * Guardian Conservator Both Less Restrictive Alternative (e.g. DPOA)

Please describe why a guardianship and/or conservatorship or a DPOA is necessary, including what specifically the Respondent needs decision-making support for, their ability to perform I/ADLs, and any other pertinent information. Please provide as much detail as possible. *

I hereby affirm, that to the best of my knowledge and belief, all statements in this form are true and accurate. *

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