Free PC-770A - Connecticut

DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION/REVIEW PC-770A REV. 10/07 TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF

STATE OF CONNECTICUT COURT OF PROBATE

RECORDED(CONFIDENTIAL VOLUME):

DISTRICT NO. WARD'S DATE OF BIRTH

Hereinafter referred to as the ward. PRESENT ADDRESS OF WARD [List both residence and domicile, if different.]

DDS REGION ADDRESS

DEPARTMENT OF DEVELOPMENTAL SERVICES PROFESSIONAL[Name job title,and telephone number]

Date of Evaluation

ASSESSMENT TEAM MEMBERS [If requested by the ward or the Court. List names, job titles, and telephone numbers.]

Date of Evaluation

1. 2. The undersigned DDS professional OR the members of the Assessment Team each hereby certify as to having personally examined or observed said ward and make a report thereof as follows: No Is the ward mentally retarded as defined in C.G.S. §1-1g? Yes Is the ward functioning adaptively and intellectually within the severe or profound range of mental retardation? (C.G.S. §45a-681, as amended.) Yes No Provide specific information regarding the severity of the ward's mental retardation and those specific areas, if any, in which he or she needs the support and protection of a guardian, together with the reasons therefor. Complete all boxes (1-5), explaining whether or not the ward has the ability to assure and/or consent to the following. If possible, provide specific examples. [1] A place of abode outside of the natural family home.

[2] Specifically designed educational, vocational, or behavioral programs.

[3] The release of clinical records and photographs.

[4] Routine, elective and emergency medical and dental care.

[5] Other specific services necessary to develop or regain to the maximum extent possible the ward's capacity to meet essential requirements. DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION/REVIEW PC-770A Continued

RESET

PERTINENT HISTORY

PHYSICAL CONDITION

[Describe physical impairments, unless described in diagnosis above. List any medication the ward may be taking and the common effects of such medication.] In my/our opinion, the guardianship should be details, use Second Sheet, PC-180.] continued modified terminated. [Give reasons for your answer. To give further

Each of the undersigned hereby certifies that he or she was appointed by the Commissioner of the Department of Developmental Services or his or her designee and did personally observe or examine the respondent on the aforementioned date. SIGNED [Include Connecticut Professional License Number, if applicable.] DDS Professional .......................................................................................................................... Print Name: OR: ASSESSMENT TEAM Member 1 .......................................................................................................................... Print Name: Member 2 .......................................................................................................................... Print Name: [Use Second Sheet, PC-180, for additional members.] DATE: DATE:

DATE:

Note:This form must be returned to the court not later than forty-five (45) days after the Cout's request for a written report on the condition of the ward. C.G.S. §45a-681(a). The court shall review each guardianship of the person with mental retardation or limited guardianship of the person with mental retardation at least every three years and shall either continue, modify, or terminate the order for guardianship. (1) The court shall receive and review written evidence as to the condition of the ward. Except as provided in subdivision (2) of this subsection, the guardian, attorney for the ward and a Department of Developmental Services professional, or, if requested by the ward or by the court, an assessment team appointed by the Commissioner of Developmental Services or his designee shall each submit a written report to the court not later than forty-five days after the court's request for such report. (2) In the case of a ward who is functioning adaptively and intellectually within the severe or profound range of mental retardation, as determined by the Department of Developmental Services, the court shall receive and review written reports as to the condition of the ward only from the guardian and the attorney for the ward, provided the court may require a Department of Developmental Services professional or assessment team to submit a written report as to the condition of such ward. Each written report shall be submitted to the court not later than forty-five days after the court's request for such report. ....The Department of Developmental Services professional or assessment team shall personally observe or examine the ward within the forty-five day period preceding the date of submission of its report. C.G.S. §45a-669(f). "Unable to meet essential requirements for his physical health or safety" means the inability through one's own efforts and through acceptance of assistance from family, friends, and other available private and public sources, to meet one's needs for medical care, nutrition, clothing, shelter, hygiene, or safety, so that, in the absence of a guardian of the person with mental retardation, serious physical injury, illness, or disease is likely to occur. C.G.S. §45a-669(g). "Unable to make informed decisions about matters related to one's care" means the inability of a person with mental retardation to achieve a rudimentary understanding, after conscientious efforts at explanation, of information necessary to make decisions about his need for physical or mental health care, food, clothing, shelter, hygiene, protection from physical abuse or harm, or other care. DDS PROFESSIONAL OR ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION/ REVIEW PC - 770A (Reverse) REV. 10/07 RESET