Confidential General Care Plan Of Conservatee Form - Superior Court Of California, County Of San Bernardino
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1
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3CONFIDENTIAL
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.:
FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO
216 Brookside Avenue
STREET ADDRESS:
216 Brookside Avenue
MAILING ADDRESS:
Redlands, CA 92373
CITY AND ZIP CODE:
Redlands District
BRANCH NAME:
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CONSERVATORSHIP OF THE
PERSON
ESTATE OF (Name):
CASE NUMBER:
CONFIDENTIAL GENERAL CARE PLAN OF CONSERVATEE
All questions on this form must be completed and answered.
If the question or blank does not apply, write “not applicable” or “none”. If you need additional space to fully respond, please note
on the form that a separate attachment is being provided and staple the attachment to the form.
PERSONAL NEEDS
Living Arrangements
Current address of Conservatee: _____________________________________ Phone: ______________
______________________________________
(Include name of facility if appropriate)
Current living arrangement:
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Personal residence
Home of relative
Board & care home
Assisted living
Skilled nursing facility
The Conservatee has been at the present residence since ________________.
If the Conservatee is in his/her personal residence, what is the current level of care?
□
No assistance needed at this time.
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Household help
____ Hours per week
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Personal caregivers
____ Hours per week
What will be necessary to keep the Conservatee in his/her residence?
_____________________________________________________________________________
_____________________________________________________________________________
If the Conservatee is not living in his/her residence:
What is the plan to return Conservatee to his/her personal residence? If there are no plans to
return the Conservatee to his/her personal residence in the foreseeable future, explain the
limitations or restrictions: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Medical Information
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Is in good health
Is developmentally disabled
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Confusion / Disorientation
Unable to read / write
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Memory loss
Deaf or communication problem
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Other ____________________________________________________________________________
Name
Purpose of Medication
Name
Purpose of Medication
GENERAL CARE PLAN FOR CONSERVATEE
Pr.C.§2352.5
Local Form (Rev. 03/21/08)
CONFIDENTIAL
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