GAPS Referral GAPS Referral Please do not include any information that would disclose the identity of the person you are requesting services for. Requester's Name Tell us how to contact you. First Name * Name of person making this request Last Name * Email * Email address for the person making this request Phone * Phone number of person making this request Your relationship to the person requesting support for: * Parent / Family Member Services Coordinator / Personal Agent School Personnel OtherOther About the person you are requesting services for County of residence * Baker Benton Clackamas Clatsop Columbia Coos Crook Curry Deschutes Douglas Gilliam Grant Harney Hood River Jackson Jefferson Josephine Klamath Lake Lane Lincoln Linn Malheur Marion Morrow Multnomah Polk Sherman Tillamook Umatilla Union Wallowa Wasco Washington Wheeler Yamhill Is the person age 18 or over? * Yes, age 18 or over No, the person is under age 18 GAPS Guardianship and HCA services are currently only available to people age 18 or older What service are you seeking? * Guardianship ISP-team Appointed Health Care Advocate Future Planning Consultation If the person qualifies for GAPS services but space is not currently available to begin services, would the person accept being added to our waitlist? * No Yes Guardianship request - Additional information required We will currently only consider guardianship cases when there are no other person or persons available to provide this support in the person's life. Does this person have contact with any family members in the area? * No Yes Are the family members willing to serve in this capacity? * No Yes Does this person have any other unpaid supporters in their life? * No Yes For example, friends, neighbors Are they willing to serve in this capacity? * No Yes Health Care Advocate (HCA) request - Additional information required What type of Health Care Advocacy support are you requesting? * HCA appointment for a specific procedure / one-time event Ongoing HCA support Remember that HCAs cannot give consent to withhold or withdraw life-sustaining support. Financial Resources Initial legal fees to establish guardianship services varies for each person, but typically costs around $2,500 to $4,500. Current rates for ongoing guardianship services start at $80 per hour. Our current rates for ISP-team Appointed Health Care Advocacy services are $50 per hour. Does the person have funds available to pay the initial legal fees to establish guardianship services? * No Yes Unknown Does the person have funds available to pay for ongoing services? * No Yes Unknown What funds are available to the person? * Special Needs Trust ABLE Account Supplemental Security Income (SSI) OtherOther Summary of situation Is this an emergency situation? * No Yes Examples of an emergency situation: medical crisis requiring a decision-maker, homeless or soon to be homeless, or death of guardian with no successor identified. Please provide a brief summary of the need for support. Limit 250 words * Please do not provide personally-identifying or confidential information. If you are human, leave this field blank. Submit