Status Report On Conservatee {PRB-PCN-005}

ATTORNEY: Name Address For court use only Phone CONSERVATOR(S): SUPERIOR COURT OF CALIFORNIA COUNTY OF SAN FRANCISCO 400 McALLISTER, ROOM 103 SAN FRANCISCO, CA 94102-4512 CONSERVATORSHIP OF PERSON ESTATE LIMITED CONSERVATORSHIP Case No. Name of Conservatee Status Report on Conservatee Confidential (Required of all Conservators of the Person one year after appointment and every two years thereafter.) All questions on the form must be completed and answered. If the question or blank does not apply, write "not applicable" or "none". If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form. I, _ _____________________________ am the Conservator of the above named Conservatee and my status report is as follows: _ Date of birth _ ________________. Present age of the Conservatee _ PERSONAL NEEDS Living Arrangements Current address of Conservatee (Include name of facility if appropriate) Current living arrangement: Personal residence Hotel Home of relative Other _ Board and care home Assisted living Skilled nursing facility Phone: _______________________________________________ _____________________________ The Conservatee has been at the present residence since __ PHYSICAL HEALTH During the past year the Conservatee's physical condition has remained about the same improved (explain) worsened (explain) _ _ ______________________________________________________________ ______________________________________________________________ During the past year the Conservatee received the following medical treatment (including check-ups, physical therapy, speech therapy, dental work, or other): Date Ailment Type of Treatment Medical Provider Form P75 STATUS REPORT ON CONSERVATEE CONFIDENTIAL 1 March 2007 American LegalNet, Inc. www.FormsWorkflow.com MENTAL HEALTH During the past year the Conservatee's mental condition has remained about the same improved (explain) _ worsened (explain) _ __________________________________________________________________________ __________________________________________________________________________ During the past year, treatment or evaluation by a psychologist, or psychiatrist was provided. was not provided. MEDICATIONS Name Purpose of Medication Name Purpose of Medication SOCIAL ACTIVITIES During the past year, the Conservatee has participated in the following activities: Outings Television / Radio Social Educational Recreational Unwilling to participate Other (i.e. reading material) Describe: Name of current activity program: Address: Phone: Name of Social Worker: Phone: Days and Hours of Attendance: Name of Regional Center: (If applicable) Unable to participate Name of Social Worker: Phone: VISITATIONS During the past year, I visited the Conservatee as follows: Dates of Visits Dates of Visits SPECIAL PROBLEMS Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or other interested persons. COMMENTS Date: Attorney Form P75 Date: Conservator March 2007 STATUS REPORT ON CONSERVATEE CONFIDENTIAL 2 American LegalNet, Inc. www.FormsWorkflow.com