Nevada Fiduciary Solutions
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WHAT IS A REPRESENTATIVE-PAYEE?
FEES
CONTACT
REFERRAL FORM
REFERRAL FORM
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Referring Person's Full Name:
First
*
Last
*
Organization
Relationship to Client
*
Your Email
*
Your Phone Number
*
Client's Full Name:
First
*
Last
*
Client's Home Address:
Street Address
*
City
*
ZIP
Date of Birth
*
Client's Phone Number
*
Type of Income - Select all That Apply
*
SSI
SSA
VA
Employer Paycheck
Private Pension
Please Enter the paying organization for the Private Pension and/or Employer Paycheck
Is the Client Homebound?
*
Yes
No
If Yes, please explain why the client cannot complete their intake at the NFS office.
If a home visit is required, please provide information related to the client’s home. For example, aggressive individuals in the home or on the property, aggressive pets, other safety concerns and special directions to the home.
Is the client aware of the referral?
*
Yes
No
Does the client present alert and oriented? Please explain.
*
Please explain why you believe this person needs a rep-payee. For example, chronic homelessness, substance abuse or addiction issues, exploitation, shut off notices for utility bills, etc.
****EPS ONLY****
Please list any concerns related to the client's finance. For example, is the client at risk of or currently being exploited?
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