Form Pc 663 - Report Of Guardian On Condition Of Individual With Developmental Disability

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PCS CODE: CDP

Approved, SCAO

TCS CODE: RGD

STATE OF MICHIGAN

FILE NO.

REPORT OF GUARDIAN ON

PROBATE COURT

CONDITION OF INDIVIDUAL WITH

COUNTY

DEVELOPMENTAL DISABILITY

This report should be completed annually by the guardian or more often if directed by the court.

In the matter of

, an individual with a developmental disability

First, middle, and last name

1. I,

, am the guardian of the individual named above, and I report for

Name (type or print)

the period

Date

2. Present age of the individual:

Individual's date of birth:

3. The current address and telephone number of the individual are:

Check here if this is a new address

4. The individual's present living arrangement is:

own home

relative's home

Relationship

hospital or medical center

guardian's home

community placement home

other:

5. The individual has been in the present residence since

. Descriptions and addresses of every

residence where the individual has lived during this reporting period and the length of stay at each residence are as follows:

6. I rate the individual's present living arrangements as

excellent.

average.

below average.

Explain if below average

7. I believe the individual is

content with the living situation.

unhappy with the living situation. I recommend a

more suitable residence as follows:

Describe

8. The individual's mental condition has

remained about the same.

improved.

deteriorated.

Describe the changes

9. The individual's physical health has

remained about the same.

improved.

deteriorated.

Describe the changes

10. The individual's social condition has

remained about the same.

improved.

deteriorated.

Describe the changes

(SEE SECOND PAGE)

USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.

Do not write below this line - For court use only

Date

Signature of reviewer

Court action to be taken

MCL 330.1631, MCR 5.409(A)

REPORT OF GUARDIAN ON CONDITION OF INDIVIDUAL WITH DEVELOPMENTAL DISABILITY

PC 663 (12/17)