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DDS Professional Or Assessment Of Person With Intellectual Disability PC-770A - Connecticut

DDS Professional Or Assessment Of Person With Intellectual Disability Form. This is a Connecticut form and can be used in Probate Statewide .
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DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH T /REVIEW PC-770A REV. 12/ 3 Page 1 STATE OF CONNECTICUT COURT OF PROBATE RECORDED(CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF Hereinafter referred to as the ward. PRESENT ADDRESS OF WARD [List both residence and domicile, if different.] DISTRICT NO. WARD'S DATE OF BIRTH DDS REGION ADDRESS DEPARTMENT OF DEVELOPMENTAL SERVICES PROFESSIONAL [Name, job title and telephone number.] Date of Evaluation ASSESSMENT TEAM MEMBERS [ List names, job titles and telephone numbers.] 1. 2. Date of Evaluation The undersigned DDS professional OR the members of the Assessment Team each hereby certify as to having personally examined or observed the ward and make a report thereof as follows: Is ward section Yes No Is the ward functioning adaptively and intellectually within the severe or profound range of intellectual disability ? (C.G.S. section 45a-681, as amended.) Yes No Provide specific information regarding the severity of the ward's l needs the support and protection of a guardian, together with the reasons therefor. and those specific areas, if any, in which he or she 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. DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH N /REVIEW American LegalNet, Inc. www.FormsWorkFlow.com PC-770A DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY/REVIEW PC-770A REV. 12/13 Page 2 [3] The release of clinical records and photographs. STATE OF CONNECTICUT COURT OF PROBATE RECORDED(CONFIDENTIAL VOLUME): [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 DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH /REVIEW T PC -770A American LegalNet, Inc. www.FormsWorkFlow.com DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY/REVIEW PC-770A REV. 12/13 Page 3 PHYSICAL CONDITION STATE OF CONNECTICUT COURT OF PROBATE RECORDED(CONFIDENTIAL VOLUME): [Describe physical impairments, unless described in diagnosis above. List any medication the respondent may be taking and the common effects of such medication.] In my/our opinion, the guardianship should be continued modified terminated. [Give reasons for your answer. [To give further details, use Second Sheet, PC-180.] Each of the undersigned hereby certifies that he or she was appointed by the Commissioner of the Department of Developmental Services or his or her designee, and did personally observe or examine the respondent on the aforementioned date. SIGNED [Include Connecticut Professional License Number, if applicable.] DDS Professional .................................................................................................................................... DATE: Print Name: OR: Member 1 .................................................................................................................................... Print Name: Member 2 .................................................................................................................................... DATE: DATE: Print Name: [Use Second Sheet, PC-180, for additional members.] Note: This form must be returned to the court not later than forty-five (45) days after the Probate Court's request for a written report on the condition of the ward. DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH /REVIEW T PC -770A American LegalNet, Inc. www.FormsWorkFlow.com
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