Advocates for Independence and Self‑Reliance
LLC
P: 248-621-9192 • F: 248-440-7602 • 321 S. Washington Ave, Royal Oak, MI 48067
A Trusted Partner
For Decisions That Matter
A dependable advocate providing expertise for dignified and sustainable independence.
Referral Form
Referral Form
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Referring source name
Referring source phone number
Referring source email address
Referring source relationship to client
Client’s name (at least first initial of the last name if confidentiality is a concern)
Type of assistance requested:
Guardianship
Conservatorship
Guardianship for an individual with a developmental disability
Trust
Power of attorney/patient advocate
Representative payee
Other
Client’s current living situation:
Own home
Apartment
AFC
Group home
Supported living
Nursing home
Assisted living
Hospital
Homeless
Incarcerated
Other
County of client’s residence and where the client is currently found if it is different from the primary residence:
Any pending investigations from police or Adult Protective Services?
Yes
No
What county or jurisdiction
File Number
Name and contact number for investigator
Client marital status:
Any natural supports or legal family?
Yes
No
Describe any natural supports or legal family:
Why are the individual’s natural supports not willing or qualified to serve?
Please describe the services provided to the client from community mental health, private duty nursing, PACE, hospice, supports coordination, day program or others.
Is this a modification?
Yes
No
Name of current fiduciary:
Reason for modification
Client’s income source and monthly amount (employment, RSDI, SSI, Pension, Trust, other)
Client’s assets and approximate value (real estate, investment accounts, insurance, annuities, stocks, bonds, etc)
Medicaid?
Yes
No
Unknown
Medicare A?
Yes
No
Unknown
Medicare B?
Yes
No
Unknown
Medicare RX?
Yes
No
Unknown
Other health insurance including vision, dental?
Submit Form
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