Capacity Declaration Conservatorship Page 3
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1
2
3CONSERVATORSHIP OF THE
PERSON
ESTATE OF (Name):
CASE NUMBER:
CONSERVATEE
PROPOSED CONSERVATEE
6. (continued)
does NOT have
a pervasive
D. Ability to modulate mood and affect. The (proposed) conservatee
has
and persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If so, complete
remainder of item 6D.)
I have no opinion.
(Instructions for item 6D: Check the degree of impairment of each inappropriate mood state (if any) as follows: a = mildly
inappropriate; b = moderately inappropriate; c = severely inappropriate.)
a
b
c
a
b
c
a
b
c
Anger
Euphoria
Helplessness
a
b
c
a
b
c
a
b
c
Anxiety
Depression
Apathy
a
b
c
a
b
c
a
b
c
Fear
Hopelessness
Indifference
a
b
c
a
b
c
Panic
Despair
E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A–6D
(1)
do NOT vary substantially in frequency, severity, or duration.
do vary substantially in frequency, severity, or duration (explain; continue on Attachment 6E if necessary):
(2)
F.
(Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g., diagnosis,
symptomatology, and other impressions) is
stated below
stated in Attachment 6F.
ABILITY TO CONSENT TO MEDICAL TREATMENT
7. Based on the information above, it is my opinion that the (proposed) conservatee
a.
has the capacity to give informed consent to any form of medical treatment. This opinion is limited to medical consent
capacity.
b.
lacks the capacity to give informed consent to any form of medical treatment because he or she is either (1) unable to
respond knowingly and intelligently regarding medical treatment or (2) unable to participate in a treatment decision by
means of a rational thought process, or both. The deficits in the mental functions described in item 6 above significantly
impair the (proposed) conservatee's ability to understand and appreciate the consequences of medical decisions. This
opinion is limited to medical consent capacity.
(Declarant must initial here if item 7b applies: __________.)
8.
Number of pages attached:
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)
CAPACITY DECLARATION—CONSERVATORSHIP
GC-335 [Rev. January 1, 2004]
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