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

CONNECTICUT PROBATE COURTS DDS Professional or Assessment Team Report / Guardianship of Person with Intellectual Disability/Review PC - 770A Rev. 1/18 CONFIDENTIAL DDS Professional or Assessment Team Report/Guardianship of Person with Intellectual Disability/Review PC - 770A Page 1 of 3 RECEIVED : Instructions: 1) A Department of Developmental Services professional or an assessment team may use this form to make a report to the court in conjunction with a review of the appointment of a guardian of a person with intellectual disability. 2)The report should be filed within 45 days of observing or examining the protected person and Probate Court Name District Number In the Matter of (Name and present address.) Hereinafter referred to as the protected person . Protected Person222s Date of Birth Department of Developmental Services Professional or Assessment Team Members (Name(s) and telephone numbers.) DDS Region 1. 2. Date of Evaluation The undersigned DDS professional or members of the assessment team state that they have personally observed or examined the protected person and submit the following report: Is the protected person functioning adaptively and intellectually within the severComplete the following sections regarding the specific areas, if any, in which the protected person needs the support and protection of a guardian, together with the reasons for your opinion. Provide specific examples, if possible. 1. A place of abode outside of the natural family home. 2. Specifically designed educational, vocational or behavioral programs . American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS DDS Professional or Assessment Team Report / Guardianship of Person with Intellectual Disability/Review PC - 770A Rev. 1/18 CONFIDENTIAL DDS Professional or Assessment Team Report/Guardianship of Person with Intellectual Disability/Review PC - 770A Page 2 of 3 3. The release of clinical records and photographs . 4. Routine, elective and emergency medical and dental care . 5. Other specific services necessary to develop or regain to the maximum extent possible the protected person222 s capacity to meet essential requirements. Does the protected person need the support and protection of a guardian with respect to the management of finances? If so, state the reasons for your opinion and provide specific examples. Pertinent History S ince the L ast R eport . Condition of the Protected Person . Medications ( List any medications the protected person may be taking and the common side effects . ) American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS DDS Professional or Assessment Team Report / Guardianship of Person with Intellectual Disability/Review PC - 770A Rev. 1/18 CONFIDENTIAL DDS Professional or Assessment Team Report/Guardianship of Person with Intellectual Disability/Review PC - 770A Page 3 of 3 Additional Comments . I/We certify that I/we were appointed by the Commissioner of the Department of Developmental Services or his or her designee, and I/we have personally observed or examined the protected person on the date listed above. For Completion by DDS Professional Signature of DDS Professional Type or Print Name Title Connecticut Professional License Number, if applicable Date For Completion by Assessment Team Members Signature of Assessment Team Member Type or Print Name Title C onnecticut Professional License Number, if applicable Date Signature of Assessment Team Member Type or Print Name Title Connecticut Professional License Number, if applicable Date American LegalNet, Inc. www.FormsWorkFlow.com