Free GC-335 CAPACITY DECLARATION--CONSERVATORSHIP - California


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Date: June 24, 2009
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State: California
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Preview GC-335 CAPACITY DECLARATION--CONSERVATORSHIP
GC-335
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

FAX NO. (Optional):

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

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
PERSON CONSERVATEE ESTATE OF (Name):

Index No. Calendar No.

CONSERVATORSHIP OF THE

: : : :

Plaintiff(s) PROPOSED CONSERVATEE

JUDICIAL SUBPOENA
CASE NUMBER

CAPACITY DECLARATION--CONSERVATORSHIP

-against-

TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER : The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply): is able to attend a court hearing to determine whether a conservator should be appointed to care for him or her. The court A. Defendant(s) : hearing is set . . . (date):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Complete. item 5, sign, and file page 1 of this form.) for . . . . . . ........ .. has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3, and file pages 1 B. through 3 of this form.) has dementia and, if so, (1) whether he or she needs to be placed in a secured-perimeter residential care facility for the C. elderly, and (2) whether he or she needs or wouldNEW YORK dementia medications. (Complete items 6 and 8 of this form THE PEOPLE OF THE STATE OF benefit from and form GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and form GC-335A.) (If more than one item is checked above, sign the last applicable page of this form or form GC-335A if item C is checked. File page 1 TO through the last applicable page of this form; also file form GC-335A if item C is checked.) COMPLETE ITEMS 14 OF THIS FORM IN ALL CASES.

GENERAL INFORMATION
1. (Name): GREETINGS: 2. (Office address and telephone number): 3. I am a. b.

an accredited practitioner of a religion whose tenets and practices call for reliance on prayer alone for healing, which religion is adhered to by the (proposed) conservatee. The (proposed) conservatee is under my treatment. (Religious practitioner may make the determination under item 5 ONLY.) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 4. (Proposed) conservatee (name): the party on whose on (date): a. I last saw the (proposed) conservateebehalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. b. The (proposed) conservatee is is NOT a patient under my continuing treatment.

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court . located at County of physician psychologist acting within the scope of my licensure a California licensed in room , on the day of , 20 , at o'clock in the noon, and at any recessed with at least two years' experience ingive evidence as a witness in this action on the part of the diagnosing dementia. or adjourned date, to testify and

ABILITY TO ATTEND COURT HEARING Witness, Honorable

, one of the Justices of the

5. A court hearing on the Court in for appointment of a conservator is set for the date indicated in item A above. (Complete a or b.) petition County, day of , 20 a. The proposed conservatee is able to attend the court hearing. b. Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items below that apply) (Attorney must sign above and type name below) on the date set (see date in box in item A above). (1) (2) for the foreseeable future. until (date): (3) Attorney(s) for and state the facts in Attachment 5): (4) Supporting facts (State facts in the space below or check this box

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:
(TYPE OR PRINT NAME) Form Adopted for Mandatory Use Judicial Council of California GC-335 [Rev. January 1, 2004]

Office and P.O. Address

Telephone No.: (SIGNATURE Facsimile No.: OF DECLARANT) E-Mail Address: CAPACITY DECLARATION--CONSERVATORSHIP Mobile Tel. No.:

Page 1 of ___ Probate Code, 811, 813, 1801, 1825, 1881, 1910, 2356.5
American LegalNet, Inc. www.USCourtForms.com

CONSERVATORSHIP OF THE

PERSON CONSERVATEE

ESTATE OF (Name): PROPOSED CONSERVATEE

CASE NUMBER:

6. EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTIONS Note to practitioner: This form is not a rating scale. It is intended to assist you in recording your impressions of the (proposed) conservatee's mental abilities. Where appropriate, you may refer to scores on standardized rating instruments. (Instructions for items 6A6C): Check the appropriate designation as follows: a = no apparent impairment; b = moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have no opinion.) A. Alertness and attention (1) Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor) a b c d e (2) Orientation (types of orientation impaired) a a a a b b b b c c c c d d d d e e e e Person Time (day, date, month, season, year) Place (address, town, state) Situation ("Why am I here?")

(3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle) a B. b c d e

Information processing. Ability to: (1) Remember (ability to remember a question before answering; to recall names, relatives, past presidents, and events of the past 24 hours) i. ii iii Short-term memory Long-term memory Immediate recall a a a b b b c c c d d d e e e

(2) Understand and communicate either verbally or otherwise (deficits reflected by inability to comprehend questions, follow instructions, use words correctly, or name objects; use of nonsense words) a b c d e (3) Recognize familiar objects and persons (deficits reflected by inability to recognize familiar faces, objects, etc.) c d a b e (4) Understand and appreciate quantities (deficits reflected by inability to perform simple calculations) a b c d e (5) Reason using abstract concepts. (deficits reflected by inability to grasp abstract aspects of his or her situation or to interpret idiomatic expressions or proverbs) c d a b e (6) Plan, organize, and carry out actions (assuming physical ability) in one's own rational self-interest (deficits reflected by inability to break complex tasks down into simple steps and carry them out) a b c d e (7) Reason logically. c d a b e C. Thought disorders (1) Severely disorganized thinking (rambling thoughts; nonsensical, incoherent, or nonlinear thinking) a b c d e (2) Hallucinations (auditory, visual, olfactory) a b c d e (3) Delusions (demonstrably false belief maintained without or against reason or evidence) a b c d e (4) Uncontrollable or intrusive thoughts (unwanted compulsive thoughts, compulsive behavior). a
GC-335 [Rev. January 1, 2004]

b

c

d

e
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CAPACITY DECLARATION--CONSERVATORSHIP

CONSERVATORSHIP OF THE

PERSON CONSERVATEE

ESTATE OF (Name): PROPOSED CONSERVATEE

CASE NUMBER:

6. (continued) does NOT have a pervasive D. Ability to modulate mood and affect. The (proposed) conservatee has and persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If so, complete remainder of item 6D.) I have no opinion. (Instructions for item 6D: Check the degree of impairment of each inappropriate mood state (if any) as follows: a = mildly inappropriate; b = moderately inappropriate; c = severely inappropriate.) c b b b c c Anger a Euphoria a Helplessness a c b b b c c Anxiety a Depression a a Apathy c b b b c c Fear Hopelessness a a Indifference a c b b c Panic Despair a a E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A6D (1) do NOT vary substantially in frequency, severity, or duration. do vary substantially in frequency, severity, or duration (explain; continue on Attachment 6E if necessary): (2)

F.

(Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g., diagnosis, symptomatology, and other impressions) is stated below stated in Attachment 6F.

ABILITY TO CONSENT TO MEDICAL TREATMENT
7. Based on the information above, it is my opinion that the (proposed) conservatee a. has the capacity to give informed consent to any form of medical treatment. This opinion is limited to medical consent capacity. b. lacks the capacity to give informed consent to any form of medical treatment because he or she is either (1) unable to respond knowingly and intelligently regarding medical treatment or (2) unable to participate in a treatment decision by means of a rational thought process, or both. The deficits in the mental functions described in item 6 above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of medical decisions. This opinion is limited to medical consent capacity. (Declarant must initial here if item 7b applies: __________.) 8. Number of pages attached: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

GC-335 [Rev. January 1, 2004]

CAPACITY DECLARATION--CONSERVATORSHIP

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