Free Superior Court of the District of Columbia - District of Columbia

SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
PROBATE DIVISION
_________ INT _________ _________ IDD _________

In re ________________________________
Ward

REPORT OF GUARDIAN I am the guardian of the above named ward, and my report to the Court is as follows: 1. Reporting period: (insert dates)

(The first date must be the date of appointment for the first report, and the ending date of the last report for all subsequent reports.) 2. Present age of ward: 3. Has the ward's address changed? Praecipe. State date of change: No Yes. Attached is a Change of Address _____

State reason(s) for change of residence: Ward's new address and telephone number are: _____

4. Ward's new residence is: Private home, owned or rented by ward Private home, not owned or rented by ward Guardian's home Foster or boarding home Home of relative who is not the guardian (relationship) Group home (insert name) Nursing home (insert name) Assisted living facility (insert name) Hospital or medical facility (insert name) Other (please specify): (If ward lives with guardian, you may skip questions 5 and 6) 5. Date of personal visits with ward: (Note: Guardian is required to visit the ward at least once per month unless otherwise directed by court order. If more than six visits occurred during the

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reporting period, then you may choose to list one visit from each 30-day period for the last six months.) 6. Were there any other contacts with the ward and/or staff at the ward's facility (e.g., telephone contacts)? No Yes Explain: ________________________________ 7. During this reporting period the ward's mental health has: Remained the same: Improved (describe): Deteriorated (describe): 8. During this reporting period the ward's physical health has: Remained the same: Improved (describe): Deteriorated (describe): 9. During this reporting period, the ward's health care professional team has changed as follows: Physician: Psychiatrist or psychologist: Social Worker or other case worker: Dentist: Podiatrist: Dietician: Therapist(s) (recreation, speech, physical, occupational): Other: 10. If ward does not reside in a facility, is the ward under a regular physician's care? No Yes If no, explain: List doctor's name, address, and telephone number: Date of last visit: 11. During this reporting period, was the ward hospitalized for any reason? No Yes Provide dates of hospitalization, facility, reason, and outcome: ______________________________________________________

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12. Have you participated in a care planning meeting during the reporting period? No Yes Provide date(s) of meeting(s): Explain goals established:

No Yes 13. Does the ward have a current health care directive? If yes, attach copy if not previously filed (copy will be kept in a confidential location) If no, explain:

14. Has the ward participated in activities during this reporting period: Yes (describe):

None available: Refuses or unable to participate: 15. I rate the ward's living arrangement as: Excellent Average Below Average (explain):

16. I believe that the ward is: Content arrangement. If unhappy, explain why: _____ I don't know.

Unhappy with living

17. I believe that the ward has the following unmet (physical, mental health, social, or basic) needs: ___________ What is being done to address these unmet needs? ______ ______

18. In my opinion this guardianship explain:

should be

should not be continued. If not,

_________________________________________________

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19. I have been appointed: My powers should Remain the same Increase as follows:

limited guardian

general guardian

_____

Decrease as follows: _____ I wish to resign as guardian. Attached is a Petition Post Appointment to resign. 20. Has guardian's mailing address or telephone number changed during the reporting period? No Yes. Attached is a Change of Address Praecipe.

21. Guardian's relationship to ward: Family Member (relation) Member of Fiduciary Panel 22. I am also the conservator ward's funds:

Friend

I am not the conservator, but I have handled the

a. Total amount received and source: _________________________________________________________ b. Total amount expended and for what purposes: ______________________________________________________ c. Balance currently in my possession or control and location: ______ I am not the conservator and have not handled the ward's funds. 23. Provide any other information that you feel the Court should know concerning the guardianship or the ward. (Note: If necessary, attach additional pages.):

___________

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VERIFICATION I being first duly sworn, on oath, depose and say that I have read the foregoing pleadings by me subscribed and that the facts therein stated are true to the best of my knowledge, information and belief. Signature of Guardian Address of Guardian City, State, Zip Code Telephone Number of Guardian E-mail Address of Guardian Subscribed and sworn to before me this day ,

Notary Public/Deputy
CERTIFICATE OF SERVICE I hereby certify that on the ______day of____________________20______, a copy of the foregoing Guardianship Report was served by first class mail, postage prepaid, upon the following parties to the above captioned case and persons granted permission to participate pursuant to SCR-PD 303 and persons who requested notice pursuant to SCR-PD 304.

Signature

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