Adult Protective Services - Online Referral Form Please enable JavaScript in your browser to complete this form.County (for billing purposes) *Other County: Please specify in the commentsButlerWarrenPrebleClintonHighlandLegal Question Posed *APS assessment for ongoing servicesGuardianship of Person & Estate 2111.031Probate Court Commitment - 5122Other: Please specify in the comments.This should match the information on the court order or agency referral.Judge or Person receiving the final report *Other party, see commentsButler, Judge John HolcombButler, APS - Kevin KurpieskiWarren, Judge Joseph KirbyClinton, Judge Chad CareyHighland, Judge Kevin GreerPike County, Judge Paul PricePreble County, Judge Jenifer OvermyerWe 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 Individual or APS Client to be Evaluated: *FirstLastIndividual's Date of Birth *DD/MM/YYYYAPS Worker's Name Or Probate Court Contact *FirstLastHow much of an EMERGENCY is this? *Within next week or so (5-8 days)Very Soon (3-4 days)Emergency, right away (1-2 days)We will make every effort to accommodate this request and will contact you immediately to let you know our availability.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 Nursing Home/Hospital/Accessible Location*There will be an additional charge for travel.Address where we will be seeing the APS Client *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of FAMILY MEMBER OR FriendFirstLastPhone for family member or friendEmail for family member or friendAttorney for the person being evaluatedFirstLastPhone for the attorneyAny 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.Please check here if you uploaded documents/filesYes, I'm attaching them here.No, we will fax/deliver them.No, I will put them in DROPBOXFile Upload for your additional information/records Click or drag files to this area to upload. You can upload up to 3 files. The COURT ORDER must accompany this referral for a Probate evaluation.For FESC USE onlyFESC Case#Assigned to:OtherCSDJROAppointment Date / TimeDateTimeSend to FESC