Confidential General Care Plan Of Conservatee Form - Superior Court Of California, County Of San Bernardino Page 2

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CONFIDENTIAL
CONSERVATORSHIP OF (Name):
CASE NUMBER:
Provider
Name
Phone number
Last visit
Physician
____________________________________________________________________________
____________________________________________________________________________
Dentist
____________________________________________________________________________
Other
____________________________________________________________________________
(e.g. visiting nurse, case worker)
Visitations
How often do you visit the Conservatee? ________________________________________________________
How often does the Conservatee receive visits from family and friends? ________________________________
Are any visitations particularly valued or upsetting to the Conservatee?
________________________________
Activities
Describe the normal activities of Conservatee:
□
Outings __________________________________________________________________________
□
Television / Radio
_________________________________________________________________
□
Social ___________________________________________________________________________
□
Educational
______________________________________________________________________
□
Recreational _____________________________
__
_______________________________________
□
□
Unwilling to participate ____________________
Unable to participate ______________________
□
Other (i.e. reading material) __________________________________________________________
Special Problems
Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or
other interested persons: ______________________________________________________________________
__________________________________________________________________________________________
FINANCIAL NEEDS
Estimated Monthly Income
Social Security
$__________
Income - other sources
$__________
Pension (type___________)
$__________
Dividends
$__________
Veterans Benefits
$__________
Rentals
$__________
Supplemental Security Income
$__________
Other
$__________
TOTAL Estimated Monthly Income
$__________
Estimated Interest from Investment $__________
Estimated Monthly Expenses
TAXES
Currently aid?
P
Next Due Date
Estimated Monthly Payment
□
□
Income
Yes
No
____________
$__________
□
□
Real Estate
Yes
No
____________
$__________
INSURANCE
Company
Premium Paid
Coverage Amount
Estimated Monthly Payment
□
□
Homeowners
______________
Yes
No
__________
$__________
□
□
Renters
______________
Yes
No
__________
$__________
□
□
Automobile
______________
Yes
No
__________
$__________
□
□
Workers Comp ______________
Yes
No
__________
$__________
□
□
Health
______________
Yes
No
__________
$__________
□
□
Life
______________
Yes
No
__________
$__________
□
□
Other
______________
Yes
No
__________
$__________
LIVING EXPENSES
Rent or Mortgage
$__________
Utilities
$__________
Nursing Home or
Telephone
$__________
Board & Care Home $__________
Laundry and Cleaning
$__________
Live-In Attendants
$__________
Clothing
$__________
Other Care Providers
$__________
Entertainment / Recreation
$__________
Medical and
Transportation
$__________
Dental Supplies
$__________
Other ____________
$__________
Food
$__________
TOTAL Estimated Monthly Expenses $__________
GENERAL CARE PLAN FOR CONSERVATEE
Pr.C.§2352.5
Local Form (Rev. 4/1/08)
CONFIDENTIAL
2

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