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Treatment Guardian Request Form

In order to request a Treatment Guardian, please use the form provided below.

Honor Guardianship will review the information provided and supply an appropriate Treatment Guardian. 

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It is the responsibility of the requestor to petition the Courts for a hearing on the matter. 

This process is separate from requesting a Treatment Guardian.

 

A Treatment Guardian can be appointed for a maximum of 12 months. 

Once the appointment expires, another appointment may be made if it is deemed necessary by the patient's treatment team.

Patient Demographic Information
Sex
Is there a history of violence?
Is there a diagnosis of polysubstance abuse?
If Yes, please select:
Next of Kin / Alternate Contact

Outpatient Provider Information
Requestor Information
Patient is currently:

Note: "Requestor" refers to the person filling out this form.

Are you the facility's primary point of contact for the patient?

Note: If the following fields are not filled out, you will be considered the primary point of contact.

If No, who is the primary point of contact at the facility for the patient?

Has a petition for TG already been filed?
Please allow up to 24 business hours for your request to be processed.
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