California > Local County > Los Angeles > Mental Health
Application For Mental Health Conservatorship Investigation - California
| Application For Mental Health Conservatorship Investigation Form. This is a California form and can be used in Mental Health Los Angeles Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH OFFICE OF THE PUBLIC GUARDIAN APPLICATION FOR MENTAL HEALTH CONSERVATORSHIP INVESTIGATION (PLEASE TYPE OR PRINT) PG OFFICE USE ONLY PG Case #:___________________________________ T-CONS NEEDED BY: ____________________________ Assign To: ________________ WT. ______________ PAGE 1 of 5 Send Original and one copy to: Office of the Public Guardian 320 West Temple St., 9th Floor Los Angeles, CA. 90012 OR FAX PER PROCEDURES (213) 974-0515 (General Info) " 974-0509 (New Cases) (323) 226-2927 (County Counsel) (213) 687-4539 (Primary PG) " 620-1405 (Back-up Fax #) (323) 225-8865 (Public Defender Fax #) Screened By: ___________________________________ Comments: ____________________________________ I. REFERRING AGENCY OR FACILITY (Must be designated by County Mental Health) Name:__________________________________________________________ Date____________________ Street:______________________________________________________________Ward/Unit ____________ City:____________________________________________State:__________________ Zip:_____________ Telephone#( )_______ - __________ Contact Person ________________________________________ II. PATIENT NAME:___________________________________________ AKA:___________________________ First Middle Last Current Address:_________________________________________________________________ (Where the patient is now) Facility Name (if any) Number Street City:_____________________ State:_________ Zip: ___________ Tel # ( )_________ - _________ Home Address:___________________________________________________________________ Faciltiy Name (if any) Number Street City:_____________________ State___________ Zip__________ Tel #( )_______ - _________ Age:_____ Birthdate_________ Birthplace_________________ Sex:______ Race/Ethnicity________________ Religion:______________ SSN:____________ Marital Status________ Co. Mental Health MIS#____________ Education Level__________________ Veterans? Yes _____ NO ________V.A. #________________ Last or Usual Occupation:___________________________________________________________________ Medi-Cal #:_________ Medicare #:___________ Driver License#____________ State:______ Expires________ Height:____________ Weight:_________________ Hair Color:______________ Eyes Color:____________ Charges:_________Booking#____________Criminal Case #:___________ Criminal Dept #_______________ Court Date: ________ Maximum Commitment Date:___________Date Declared Incomptent:_____________ #45 (LPS Referral) Confidential Patient Information See Welfare & Institutions Code 5328 American LegalNet, Inc. www.FormsWorkflow.com LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH OFFICE OF THE PUBLIC GUARDIAN APPLICATION FOR MENTAL HEALTH CONSERVATORSHIP INVESTIGATION PATIENT NAME:____________________________________ (PLEASE TYPE OR PRINT) Page 2 of 5 TEL # PARTNERS ISA, SPOUSE, RELATIVES, FRIENDS, LANDLORD, SIGNIFICANT OTHERS III. RELATION 1. 2. 3. 4. IV. INCOME (List all known or possible sources of income) SOURCE PAYEE NAME ADDRESS MONTHLY AMT ____ Social Security/SSI ____ Veterans Comp/Retirement ____ Other Specify____________ ____ Other Specify____________ V. ASSETS ________________________________ __________________ ________________________________ __________________ ________________________________ __________________ ________________________________ __________________ [ ] Real Property [ ] Bank Account(s) [ ] Furniture [ ] Car/Motor Vehicle [ ] Mobile Home [ ] Life Insurance [ ] Stocks/Bonds/Notes [ ] Other (Specify):___________________________________________________________________________ Describe all known assets: ITEM LOCATION OR ID# VALUE (If known) 1._____________________________________________________________________________ 2.__________________________________________________________________________________________ 3.__________________________________________________________________________________________ 4.__________________________________________________________________________________________ 5.__________________________________________________________________________________________ Remarks (If any)_____________________________________________________________________________ ____________________________________________________________________________________________ #45 (LPS Referral) Confidential Patient Information See Welfare & Institutions Code 5328 American LegalNet, Inc. www.FormsWorkflow.com LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH OFFICE OF THE PUBLIC GUARDIAN DECLARATION IN SUPPORT OF LPS CONSERVATORSHIP PLEASE TYPE OR PRINT Page 3 of 5 VI. PATIENT _________________________Facility/Agency__________________________________ 72 Hr. Hold date______________ 14 Day Cert. Eff. Date____________* 30 Day Cert. Eff. Date___________ *Note: No T-Cons. will be granted on 30 day certs. Application must be received by PG with a minimum of 25 days remaining on the 30 day certification. IS PATIENT CURRENTLY IN AN INTENSIVE TREATMENT FACILITY? Yes [ ] No [ ] Penal Code No._______________________ Exp. Date_________________ (If no I hereby certify that further examination on an in-patient basis is not necessary for a determination that this patient is gravely disabled). I am recommending conservatorship for the above-referenced person. I believe he or she is not able to provide for his or her personal needs for food, clothing, or shelter as a result of a mental disorder and is: [ ] Unwilling or [ ] Unable to accept voluntary treatment. Diagnosis:_________________________________________________________________________________ DSM IV Classification number____________________________ Specific facts or incidents that demonstrate the patient is gravely disabled and is unwilling or unable to accept voluntary treatment: (Attach additional documentation if necessary)__________________________________ Yes [ ] No [ ] Does the patient have the capacity to complete an affidavit of voter registration and register to vote? Yes [ ] No [ ] The patient's privilege of possessing a license to operate a motor vehicle should be revoked. Reasons:_________________________________________________________________________________ Yes [ ] No [ ] Would the possession of a firearm or other deadly weapon by the patient present a danger to his or her safety or to other persons? Reasons:_________________________________________________________________________________ VII. I declare under penalty or perjury that the f
|
|||||||
