Free GC-380 PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT (Probate Conservatorship) - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):

Index No.
FOR COURT USE ONLY

GC-380

TELEPHONE AND FAX NOS.:

: Plaintiff(s)
ATTORNEY FOR (Name):

Calendar No.

: : : :

JUDICIAL SUBPOENA

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

-against-

CONSERVATORSHIP OF THE

Defendant(s) : ......................................................
CONSERVATEE
CASE NUMBER:

PERSON

ESTATE

OF (Name):

PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL YORK THE PEOPLE OF THE STATE OF NEWTREATMENT
1. Petitioner (name): requests that a. the conservatee be adjudged to lack the capacity to give informed consent for medical treatment or healing by prayer. b. the conservator of the person be granted the exclusive authority to give consent for medical treatment or healing by prayer that the conservator in good faith based on medical advice determines to be necessary. GREETINGS: a licensed medical practitioner a licensed psychologist within the scope of his or c. the treatment be performed by her licensure an accredited practitioner of a religion that relies on prayer alone for healing. d. e.

TO

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before orders related to dementia treatment or placement as specified in the Attachment Requesting Special Orders Regarding , the Honorable granted. (Attach form GC-313.) at the Court Dementia be located at Countyorder dated (specify): of the made under Probate Code section 1880 in room be revoked, on the be modified as specified in 20 day of , Attachment 1e , at o'clock in the asnoon, and at any recessed be modified follows (specify): or adjourned date, to testify and give evidence as a witness in this action on the part of the

Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.
f.

Witness, Honorable Court in County,

other orders be granted

as specified in Attachment 1f

as follows (specify):

, one of the Justices of the

day of

, 20

(Attorney must sign above and type name below)

g. Letters of Conservatorship be reissued to include a statement that conservator has the powers requested in this petition. Attorney(s) for 2. There is no form of medical treatment for which the proposed conservatee has the capacity to give informed consent. 3. Attached to this petition is a declaration executed by a licensed physician stating that the conservatee lacks the capacity to give informed consent for any form of medical treatment and giving reasons andOffice andbasis for this conclusion. (Label as Attachthe factual P.O. Address ment 3.) 4. Conservatee section 2355(b). is is not an adherent of a religion that relies Telephone No.: healing as defined in Probate Code on prayer alone for

Form Approved by the Judicial Council of California GC-380 [Rev. January 1, 1998] Mandatory Form [1/1/2000]

PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT
(Probate Conservatorship)

Facsimile No.: E-Mail Address: (Continued on reverse) Mobile Tel. No.:

Probate Code, § 1880 et seq.

American LegalNet, Inc. www.USCourtForms.com

CONSERVATORSHIP OF (Name): CONSERVATEE

CASE NUMBER:

5. ATTENDANCE AT THE HEARING Conservatee a. will attend the hearing. b. is able but unwilling to attend the hearing AND does does not wish to contest this petition. is unable to attend the hearing because of medical inability. An affidavit or certificate of a licensed medical practitioner or c. an accredited religious practitioner is affixed as Attachment 5c. d. is not the petitioner, is out of state, and will not attend the hearing. 6. Special notice has notice in Attachment 6.) 7. has not been requested. (Specify the names and addresses of persons requesting special

Filed with this petition is a proposed Order Appointing Court Investigator (form GC-330) that specifies the duties to be performed before granting an order relating to medical consent.

8. The names, residence addresses, and relationships of the spouse and all relatives within the second degree of the conservatee so far as known to petitioner are listed below listed in Attachment 8. Relationship and name a. Spouse: Residence address

b.

9. Number of pages attached: _____ Date:
* (Signature of all petitioners also required (Prob. Code, § 1020).)
(SIGNATURE OF ATTORNEY *)

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

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(TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER)

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(TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER) GC-380 [Rev. January 1, 1998]

PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT
(Probate Conservatorship)

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