APS & Probate Court Referrals – Forensic Evaluation Service Center

Adult Protective Services - Online Referral Form

County (for billing purposes) *

Legal Question Posed *

Judge or Person receiving the final report *

We will only send probate court ordered reports to the presiding judge, and then the court can distribute. We will not send reports to any other parties.

Name of the Alleged Incompetent or Potential Ward or APS Client to be Evaluated: *

First

Last

Individual's Date of Birth *

DD/MM/YYYY

APS Worker's Name Or Probate Court Contact *

First

Last

APS Worker or Probate Court contact email *

APS Worker or Probate Court Phone *

Where will we be seeing the APS or Probate Client? *

At our Fairfield Office - someone will bring them
*At the APS Client's Private Residence with an APS Worker
*At a Mental Health Agency/Nursing Home/Hospital/Accessible Location
Other - specified in comments

*There will be an additional charge for travel.

Address where we will be seeing the APS or Probate Client

Address Line 1

Address Line 2

City

State

Zip Code

Name of Professional, family, or friend who will coordinate this evaluation

First

Last

Phone for Professional, family, or friend who will coordinate this evaluation

Email for Professional, family, or friend who will coordinate this evaluation

Attorney for the person being evaluated

First

Last

Phone for the attorney

Email for the attorney

Any additional comments?

Please list any relevant issues here for consideration. ALL PROBATE cases must be accompanied by a SIGNED Court order to conduct the evaluation.

Are you uploading any documents/files?

Yes, I'm attaching them here.
No, I will send them in an email.
No, we will fax or deliver them.

File Upload for your additional information/records

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

The COURT ORDER must accompany this referral for a Probate evaluation.

For FESC USE only

Date referral was received

FESC State Form #

Assigned to:

Appointment Date / Time

Date

Time

The court/agency needs this report by *