Free GC-313 ATTACHMENT REQUESTING SPECIAL ORDERS REGARDING DEMENTIA (Petition for Exclusive Authority to Give Consent for Medical Tre - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
CONSERVATORSHIP OF (Name):

Index No.
CASE NUMBER:

GC-313

: :

Calendar No.

CONSERVATEE

JUDICIAL SUBPOENA ATTACHMENT REQUESTING SPECIAL ORDERS REGARDING DEMENTIA Plaintiff(s) (Petition for Exclusive Authority to Give Consent for Medical Treatment (form GC-380)) -against: (Petition for Appointment of Probate Conservator (form GC-310))
: 1. Petitioner requests that the conservator of the person be authorized to place the conservatee in a secured perimeter residential care facility for the elderly operated under Health and Safety a. Code section 1569.698 and which has a care plan that meets the requirements of California Code of Regulations, title 22, : section 87724. b. to authorize the administration of medications Defendant(s) the care and treatment of dementia. appropriate for : ......................................................
2. The conservatee or proposed conservatee has dementia as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. 3. A medical declaration executed by a licensed physician, or a licensed psychologist acting within the scope of his or her licensure with at least two years experience in diagnosing dementia, a. TO has been filed. will be filed before the hearing. b. 4. Restricted placement. The conservatee needs or would benefit from placement as requested in item 1a. The conservatee lacks capacity to give informed consent to this placement. The placement requested is the least restrictive placement GREETINGS: appropriate to the needs of the conservatee.

THE PEOPLE OF THE STATE OF NEW YORK

5.

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Dementia medications. The conservatee needs or would benefit from medications appropriate to the care and treatment of , the Honorable at the Court dementia. The conservatee lacks capacity to give informed consent to the administration of those medications. located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 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. Witness, Honorable County, , one of the Justices of the day of , 20

Court in

(Attorney must sign above and type name below)

Attorney(s) for

Office and P.O. Address

Form Adopted for Mandatory Use Judicial Council of California GC-313 [Rev. January 1, 2003]

ATTACHMENT REQUESTING SPECIAL ORDERS REGARDING DEMENTIA
(Petition for Exclusive Authority to Give Consent for Medical Treatment) (Petition for Appointment of Probate Conservator)

Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.:

Probate Code, § 2356.5

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