Free GC-335A DEMENTIA ATTACHMENT TO CAPACITY DECLARATION--CONSERVATORSHIP - California

GC­335A
CONSERVATORSHIP OF THE

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. CONSERVATEE PROPOSED CONSERVATEE : Index No. ATTACHMENT TO FORM GC-335, CAPACITY DECLARATION--CONSERVATORSHIP, ONLY FOR (PROPOSED) CONSERVATEE WITH DEMENTIA : Calendar No.

PERSON

ESTATE OF (Name):

CASE NUMBER:

9. It is my opinion that the (proposed) conservatee HAS does NOT have dementia as defined in the current : edition of Diagnostic and Statistical Manual of Mental Disorders. JUDICIAL SUBPOENA Plaintiff(s) a. Placement of (proposed) conservatee. (If the (proposed) conservatee requires placement in a secured-perimeter -against: residential care facility for the elderly, please complete items 9a(1)­9a(5).) (1) The (proposed) conservatee needs or would benefit from placement in a restricted and secure facility because : (state reasons; continue on Attachment 9a(1) if necessary):

: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on . (2) . . The .(proposed) .conservatee's. mental. function .deficits,. based . . . my assessment in item 6 of form GC-335, include (describe; continue on Attachment 9a(2) if necessary): THE PEOPLE OF THE STATE OF NEW YORK Defendant(s) :

(3)

The (proposed) conservatee HAS capacity to give informed consent to this placement. The (proposed) conservatee does NOT have capacity to give informed consent to this placement. The deficits in mental function assessed in item 6 of form GC-335 and described in item 9a(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of his or her actions with regard to giving informed consent to placement in a restricted and secure environment.

(4) TO

GREETINGS:
(5) b. A locked or secured-perimeter facility is is NOT the least restrictive environment appropriate to the needs ofCOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE the (proposed) conservatee.

, the Honorable at the Administration of dementia medications. (If the (proposed) conservatee Court administration of psychotropic requires County of medications appropriate to the care of located at please complete items 9b(1)­9b(5).) dementia, , on the day or , 20 , at o'clock in the noon, and at any recessed (1) in room The (proposed) conservatee needsof would benefit from the following psychotropic medications appropriate to the or care of dementia, for the reasons stated in item a witness in this action continue on of the adjourned date, to testify and give evidence as 9b(5) (list medications; on the part Attachment 9b(1) if necessary):

(2)

The (proposed) conservatee's mental function deficits, based on my a contempt of court 6 of will make youinclude to Your failure to comply with this subpoena is punishable as assessment in item and form GC-335, liable (describe; whose behalf this subpoena if necessary): the party on continue on Attachment 9b(2)was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.

(3) (4)

Witness, Honorable , one of the Justices of the The (proposed) conservatee HAS capacity to give informed consent to the administration of Court in psychotropicCounty, day of , 20 dementia. medications appropriate to the care of
The (proposed) conservatee does NOT have the capacity to give informed consent to the administration of psychotropic medications appropriate to the care of dementia. The deficits in mental function assessed (Attorney must sign above and type name below) in item 6 of form GC-335 and described in item 9b(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate his or her actions with regard to giving informed consent to the administration of psychotropic medications for the treatment of dementia.

(5)

Attorney(s) of The (proposed) conservatee needs or would benefit from the administrationfor the psychotropic medications listed in item 9b(1) because (state reasons; continue on Attachment 9b(5) if necessary):

10. Number of pages attached:

Office and P.O. Address

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:

Form Adopted for Mandatory Use Judicial Council of California GC­335A [New January 1, 2004]

Telephone No.: Facsimile No.: (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) E-Mail Address: Mobile DEMENTIA ATTACHMENT TO Tel. No.: CAPACITY DECLARATION--CONSERVATORSHIP

Page 1 of 1 Probate Code, § 2356.5

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