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.
Name of person making this request
Email address for the person making this request
Phone number of person making this request

About the person you are requesting services for

Is the person age 18 or over? *
GAPS Guardianship and HCA services are currently only available to people age 18 or older
What service are you seeking? *
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? *

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? *
Are the family members willing to serve in this capacity? *
Does this person have any other unpaid supporters in their life? *
For example, friends, neighbors
Are they willing to serve in this capacity? *

Health Care Advocate (HCA) request - Additional information required

What type of Health Care Advocacy support are you requesting? *
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? *
Does the person have funds available to pay for ongoing services? *
What funds are available to the person? *

Summary of situation

Is this an emergency situation? *
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 do not provide personally-identifying or confidential information.

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2405 Front Street NE, Suite 120, Salem, OR 97301  |  (503) 581-2726
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