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Assessment Team Evaluation Guardianship Of Person With Intellectual Disabilit PC-770 - Connecticut

Assessment Team Evaluation Guardianship Of Person With Intellectual Disabilit Form. This is a Connecticut form and can be used in Probate Statewide .
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ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH T PC-770 REV. 12/ 3 Page 1 STATE OF CONNECTICUT : COURT OF PROBATE RECORDED(CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF DISTRICT NO. RESPONDENT'S DATE OF BIRTH Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [List both residence and domicile, if different.] DDS REGION ADDRESS ASSESSMENT TEAM MEMBERS [ List names, job titles, and telephone numbers.] Date of Evaluation 1. 2. The undersigned members of the Assessment Team state that they have personally examined or observed said respondent and hereby make their report as follows: Is Is your conclusion supported by a psychological evaluation? Yes section Yes No No If "yes," please attach. Provide specific information regarding the severity of the l f the respondent and those specific areas, if any, in which he or she needs the support and protection of a guardian, together with the reasons therefor. Complete all boxes (1-5), explaining whether or not the respondent has the ability to assure and/or consent to the following. If possible, provide specific examples. [1] A place of abode outside of the natural family home. [2] Specifically designed educational, vocational or behavioral programs. ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH N PC-770 American LegalNet, Inc. www.FormsWorkFlow.com ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-770 REV. 12/13 Page 2 [3] The release of clinical records and photographs. STATE OF CONNECTICUT : RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [4] Routine, elective and emergency medical and dental care. [5] Other specific services necessary to develop or regain to the maximum extent possible the ward's capacity to meet essential requirements. PERTINENT HISTORY ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH T PC -770 American LegalNet, Inc. www.FormsWorkFlow.com ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH T. PC-770 REV. 12/ 3 Page 3 PHYSICAL CONDITION STATE OF CONNECTICUT : RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Describe physical impairments, unless described in diagnosis above. List any medication the respondent may be taking and the common effects of such medication.] ADDITIONAL COMMENTS: We hereby certify that we were appointed by the Commissioner of the Department of Developmental Services or his or her designee, and we have personally observed or examined such respondent on the aforementioned date. SIGNED [Assessment Team Members (Include Connecticut Professional License Number, if applicable.)] Member 1 .................................................................................................................................... Print Name: Member 2 .................................................................................................................................... DATE: DATE: Print Name: [Use Second Sheet, PC-180, for additional members.] Note to Assessment Team Members: This form should be returned to the court at least three (3) days prior to the hearing. ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH . T PC -770 American LegalNet, Inc. www.FormsWorkFlow.com
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