COURT INVESTIGATOR'S OFFICE BERKELEY COURTHOUSE 2120 MARTIN LUTHER KING, JR. WAY BERKELEY, CA 94704 SUPERIOR COURT - ALAMEDA COUNTY STATUS REPORT ON CONSERVATEE (Local Court Rule 7.870) In the Matter of the Conservatorship of: ) ) ) ) PROBATE NUMBER: HEARING DATE: ,Conservatee THIS IS A CONFIDENTIAL REPORT CI revised 1 31 14 1 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATUS REPORT Name of Conservatee: _____________________________________________ Probate No.: ___________________ Current Residence: _____________________________________________________________________________ _______________________________________________________________Phone:__________________________ Please provide the following information about the conservatee. 1. Current Health Status a) Doctor's Name: _________________________________Date of last appointment: ___________________ b) Describe conservatee's current health status, including diagnoses. _____________________________ __________________________________________________________________________________________ c) Describe any significant health changes since the last review. __________________________________ __________________________________________________________________________________________ 2. Current Function Level a) Describe conservatee's ability to care for self _________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ b) Describe conservatee's communication/understanding level ___________________________________ __________________________________________________________________________________________ c) Describe any significant changes in the conservatee's ability to care for self or communicate/understand since the last review. _________________________________________________________________________________________ _________________________________________________________________________________________ 3. Current General Well Being a) Describe the current living situation (own home/board & care/skilled nursing/etc.) ________________________________________________________________________________________ b) If the conservatee lives at home, does he/she receive IHSS benefits? ___________________________ If, yes, name of care provider__________________________________________Phone________________ Name of social worker at IHSS _________________________________________Phone_______________ c) Describe any plans to change the living situation _____________________________________________ ________________________________________________________________________________________ d) Date of last visit by conservator ____________________________________________________________ Frequency of visits by conservator ___________________________________________________________ Does the conservatee have other visitors? ____________________________________________________ 4. Current estate situation a) Present market value ____________________________________________________________________ b) Adequate to meet needs of the conservatee ________________________________________________ Explain_________________________________________________________________________________ c) If you plan to make significant changes in the way the estate is being handled, please describe them. (e.g., a reverse annuity mortgage in order to keep the conservatee in own home). ____________________________________________________________________________________ 5. Name and phone no. of Day Program, if applicable____________________________________________ 6. Conservator's comments - Please indicate any unusual problems/successes you wish the court to be aware of that occurred since the last review. __________________________________________ __________________________________________________________________________________________ I declare under penalty of perjury that the foregoing is true and correct. Date signed: ______________________________ __________________________________________ Conservator's Signature _________________________________________________________________________________________ Mailing Address City, State, Zip Code _______________________________________________ Telephone Number/Email address *Attach additional pages if necessary. CONFIDENTIAL STATUS REPORT CI revised 1 31 14 2 American LegalNet, Inc. www.FormsWorkFlow.com