Fillable Capacity Declaration Conservatorship printable pdf download

GC-335

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

To keep other people from

seeing what you entered on

FAX NO. (Optional):

TELEPHONE NO.:

your form, please press the

E-MAIL ADDRESS (Optional):

Clear This Form button at the

ATTORNEY FOR (Name):

end of the form when finished.

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CONSERVATORSHIP OF THE

PERSON

ESTATE

OF (Name):

PROPOSED CONSERVATEE

CONSERVATEE

CASE NUMBER

CAPACITY DECLARATION—CONSERVATORSHIP

TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER

The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply):

is able to attend a court hearing to determine whether a conservator should be appointed to care for him or her. The court

. (Complete item 5, sign, and file page 1 of this form.)

hearing is set for (date):

has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3, and file pages 1

through 3 of this form.)

has dementia and, if so, (1) whether he or she needs to be placed in a secured-perimeter residential care facility for the

elderly, and (2) whether he or she needs or would benefit from dementia medications. (Complete items 6 and 8 of this form

and form GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and form GC-335A.)

(

If more than one item is checked above, sign the last applicable page of this form or form GC-335A if item C is checked. File page 1

through the last applicable page of this form; also file form GC-335A if item C is checked.)

COMPLETE ITEMS 1–4 OF THIS FORM IN ALL CASES.

GENERAL INFORMATION

(Name):

(Office address and telephone number):

I am

a California licensed

physician

psychologist acting within the scope of my licensure

with at least two years' experience in diagnosing dementia.

an accredited practitioner of a religion whose tenets and practices call for reliance on prayer alone for healing, which

religion is adhered to by the (proposed) conservatee. The (proposed) conservatee is under my treatment. (Religious

practitioner may make the determination under item 5 ONLY.)

(Proposed) conservatee (name):

I last saw the (proposed) conservatee on (date):

The (proposed) conservatee

is NOT a patient under my continuing treatment.

ABILITY TO ATTEND COURT HEARING

A court hearing on the petition for appointment of a conservator is set for the date indicated in item A above. (Complete a or b.)

The proposed conservatee is able to attend the court hearing.

Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items below that

apply)

on the date set (see date in box in item A above).

(1)

(2)

for the foreseeable future.

(3)

until (date):

(4)

Supporting facts (State facts in the space below or check this box

and state the facts in Attachment 5):

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

Page 1 of ___

Form Adopted for Mandatory Use

CAPACITY DECLARATION—CONSERVATORSHIP

Probate Code, §§ 811,

Judicial Council of California

813, 1801, 1825,

GC-335 [Rev. January 1, 2004]

1881, 1910, 2356.5

Capacity Declaration Conservatorship

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