California > Judicial Council > Probate Guardianship-Conservatorship
Capacity Declaration-Conservatorship GC-335 - California
| Capacity Declaration-Conservatorship Form. This is a California form and can be used in Probate Guardianship-Conservatorship Judicial Council . |
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GC-335 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : PERSON CONSERVATEE ESTATE OF (Name): Index No. Calendar No. CONSERVATORSHIP OF THE : : : : Plaintiff(s) PROPOSED CONSERVATEE JUDICIAL SUBPOENA CASE NUMBER CAPACITY DECLARATION--CONSERVATORSHIP -against- TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER : The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply): is able to attend a court hearing to determine whether a conservator should be appointed to care for him or her. The court A. Defendant(s) : hearing is set . . . (date):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Complete. item 5, sign, and file page 1 of this form.) for . . . . . . ........ .. has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3, and file pages 1 B. through 3 of this form.) has dementia and, if so, (1) whether he or she needs to be placed in a secured-perimeter residential care facility for the C. elderly, and (2) whether he or she needs or wouldNEW YORK dementia medications. (Complete items 6 and 8 of this form THE PEOPLE OF THE STATE OF benefit from and form GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and form GC-335A.) (If more than one item is checked above, sign the last applicable page of this form or form GC-335A if item C is checked. File page 1 TO through the last applicable page of this form; also file form GC-335A if item C is checked.) COMPLETE ITEMS 14 OF THIS FORM IN ALL CASES. GENERAL INFORMATION 1. (Name): GREETINGS: 2. (Office address and telephone number): 3. I am a. b. an accredited practitioner of a religion whose tenets and practices call for reliance on prayer alone for healing, which religion is adhered to by the (proposed) conservatee. The (proposed) conservatee is under my treatment. (Religious practitioner may make the determination under item 5 ONLY.) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 4. (Proposed) conservatee (name): the party on whose on (date): a. I last saw the (proposed) conservateebehalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. b. The (proposed) conservatee is is NOT a patient under my continuing treatment. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court . located at County of physician psychologist acting within the scope of my licensure a California licensed in room , on the day of , 20 , at o'clock in the noon, and at any recessed with at least two years' experience ingive evidence as a witness in this action on the part of the diagnosing dementia. or adjourned date, to testify and ABILITY TO ATTEND COURT HEARING Witness, Honorable , one of the Justices of the 5. A court hearing on the Court in for appointment of a conservator is set for the date indicated in item A above. (Complete a or b.) petition County, day of , 20 a. The proposed conservatee is able to attend the court hearing. b. Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items below that apply) (Attorney must sign above and type name below) on the date set (see date in box in item A above). (1) (2) for the foreseeable future. until (date): (3) Attorney(s) for and state the facts in Attachment 5): (4) Supporting facts (State facts in the space below or check this box I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME) Form Adopted for Mandatory Use Judicial Council of California GC-335 [Rev. January 1, 2004] Office and P.O. Address Telephone No.: (SIGNATURE Facsimile No.: OF DECLARANT) E-Mail Address: CAPACITY DECLARATION--CONSERVATORSHIP Mobile Tel. No.: Page 1 of ___ Probate Code, §§ 811, 813, 1801, 1825, 1881, 1910, 2356.5 American LegalNet, Inc. www.USCourtForms.com CONSERVATORSHIP OF THE PERSON CONSERVATEE ESTATE OF (Name): PROPOSED CONSERVATEE CASE NUMBER: 6. EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTIONS Note to practitioner: This form is not a rating scale. It is intended to assist you in recording your impressions of the (proposed) conservatee's mental abilities. Where appropriate, you may refer to scores on standardized rating instruments. COURT (Instructions for items 6A6C): Check the appropriate designation as follows: a = no apparent impairment; b = moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have no opinion.) COUNTY OF A. Alertness and attention a b ...................................................... : Index No. Calendar No. (1) Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor) : c d e (2) Orientation (types of orientation impaired) a a a a b b b b c c c d d d Plaintiff(s) Person : : JUDICIAL SUBPOENA -againste e e Time (day, date, month, season, year) : Place (address, town, state) : c d e Situation ("Why am I here?") Defendant(s) : ...................................................... c d e (3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle) a B. b Information processing. Ability to: THE PEOPLE OF THE STATE OF NEW YORK (1) Remember (ability to remember a question before answering; to recall names, relatives, past presidents, and events of the TO past 24 hours) i. ii iii Short-term memory Long-term memory GREETINGS: Immediate recall a a a b b b c c c d d d e e e (3) Recognize familiar objects and persons (deficits reflected by inability to recognize familiar faces, objects, etc.) c d a b e WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court (2) Understand and communicate either verbally or otherwise (deficits reflected by inability to comprehend questions, follow located at instructions,County of correctly, or name objects; use of nonsense w
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