Free REMEMBER USE BLACK INK PEN ONLY - California

INSTRUCTIONS 2 OF 4 DOCUMENTS NEEDED WHEN REQUESTING REAPPOINTMENT Letters on the left hand side of these instructions match numbers on the form REMEMBER USE BLACK INK PEN ONLY PHYSICIAN'S DECLARATION CONSERVATOR: PLEASE COMPLETE THE TOP OF THE FORM: A: Lefthand side: Fill in the Conservatee's (patient's) name. If residing in a facility, include the facility name, address, and telephone # B:. Righthand side: Fill in the Court Case #, Conservatee's Age, Sex, and Birthdate. STOP -- The remainder of this form must be completed by the conservatee's psychiatrist or a licensed psychologist who has practiced for at least five (5) years. The form will not be accepted by the court if completed by a general practitioner / medical doctor / social worker or nurse. The Court will accept one doctor's signature, if you are unable to get a second doctor's signature. ONCE THE ORIGINAL FORM IS COMPLETED AND SIGNED BY THE DOCTOR(S) YOU MUST FILE THE FORM WITH THE COURT. If you have questions, please call the Mental Health Clerk's Office at (323) 226-2917 or 2918.

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Conservatorship Re-evaluation Physicians Declaration A): NAME AND ADDRESS OF CONSERVATEE: _______________________________________ _______________________________________ _______________________________________ B): COURT CASE # ______________ AGE: ___________ SEX: MALE FEMALE BIRTHDATE: ___________

====================================================================================== PREVIOUS DIAGNOSIS______________________________________________________ DATE OF EVALUATION_____________________________________________________

Please LEGIBLY complete the following four areas of interest to assist the Judge in making a decision as to whether on not the above-referenced person should continue to have a Conservatorship: 1) Is there a mental disorder? YES NO Please give a DIAGNOSIS and explain the symptoms in lay language.

2) Can individual provide for basic needs; food, clothing, shelter in an unsupervised setting? YES NO WHY? State facts in lay language.

3) Do you feel this individual is capable and willing to accept voluntary treatment? YES NO WHY? State facts in lay language.

4) Does this individual have the capacity of knowingly and intelligently accepting or refusing to accept prescribed medication? YES NO I declare under penalty of perjury, under the Laws of the State of California, that the foregoing is true and correct to the best of my knowledge. Executed on ___________________ at _______________________, California (Date) (City) _________________________ Signature of first (1) Evaluator _________________________ Type name of first (1) Evaluator ____________________________ Signature of second (2) Evaluator _____________________________ Type name of second (2) Evaluator