Kansas Guardianship Program

3248 Kimball Avenue, Manhattan, KS 66503-0353
(785)587-8555     1-800-672-0086     www.ksgprog.org

Guardian and/or Conservator Monthly Report

Items in red are required fields

Month: Year: Recruiter:
Guardian (G/C)Is this new?
Name: Yes     No
Address: Yes     No
E-mail: Yes     No
Phone: Yes     No

Ward (W/C)Name:Is this new?
Provider/Facility/Address: Yes     No

Personal Involvement With Individual Served:

  1. Number of visits with W/C (If None, please explain)
  2. Approximate number of phone calls and/or written communications with or regarding individual
  3. Approximate hours per month devoted to guardianship or conservatorship responsibilities

Advocacy and Protective Services Provided

Residential Supports and Services
Community Living with I/DD support   Community Living with Behavioral Health support   Assisted Living   Nursing Facilty   State Institution   Medical Hospital   Homeless

Managed Care Organization/MCO-Insurance
Aetna   Sunflower   United   None
MCO Care Coordinator Name, phone, email:

Case Manager or Social Worker Name, phone, email:

Are current services: Meeting the needs   Changes needed - if so, what?

Changes observed in medical, physical, or mental health of individual served: Yes   No

Problems relating to guardianship: Yes   No   If yes, please explain

Joyous or noteworthy events with individual served:

Financial Information

Conservator   Guardian with Financial Authority to $10,000   Not Conservator

Who serves as payee?   Guardian or Conservator   A Payee Program   Name:   Service Provider   Name:

Income Benefit Source(s)   Social Security $   VA Benefit $   Railroad Benefits $   Pension $   Earned Income: $ Source:

Bank   Checking Account Balance $   Savings Account Balance $

Funeral/Burial Fund Approximate Value (enter '0' if none) $   Special Needs Trust Approximate Value (enter '0' if none) $

Annual Court Reports filed with the court Yes   No     Copy to KGP Yes   No

Notes to KGP.