ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY TELEPHONE NUMBER: FAX NO. (Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1035 Palm Street, Room 385 Same as above San Luis Obispo, CA 93408 San Luis Obispo Division LPS CONSERVATORSHIP OF: CASE NUMBER: CONFIDENTIAL MEDICAL INFORMATION IN SUPPORT OF REAPPOINTMENT OF LPS CONSERVATOR DECLARATION OF PHYSICIANS OR QUALIFIED LICENSED PSYCHOLOGISTS FOR REAPPOINTMENT OF LPS CONSERVATORSHIP Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15 CONFIDENTIAL MEDICAL INFORMATION Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com LPS CONSERVATORSHIP OF: CASE NUMBER DECLARATION OF PHYSICIAN OR QUALIFIED LICENSED PSYCHOLOGIST FOR REAPPOINTMENT OF LPS CONSERVATORSHIP (Welfare & Institutions Code §5361) The renewal of the conservatorship of __________________________________for an additional one year period IS NOT recommended because this person is no longer gravely disabled as defined under §5008(h)(1)(a) of the Welfare & Institutions Code. The renewal of the conservatorship of ___________________________________for an additional one year period IS recommended because this person is still gravely disabled as defined under §5008(h)(1)(a) of the Welfare & Institutions Code. Date of current evaluation: ____________________________. 1. Is there a current mental disorder? ____________________________________. 2. Current Diagnosis:_________________________________________________. 3. Current Mediations:_________________________________________________ __________________________________________________________________. 4. Please explain the symptoms.________________________________________ ___________________________________________________________________ __________________________________________________________________. 5. Can the individual provide for his or her basic needs (i.e., food, clothing, or shelter) in an unsupervised setting? Why do you feel he or she can or cannot? ____ ___________________________________________________________________ __________________________________________________________________. 6. Conservatee's Current Placement Level of Care __________________________. The least restrictive level of care in which this person can be treated is: Locked IMD Skilled Nursing Facility Licensed Board and Care Other _____________________. This person lacks capacity to give informed consent, or is unable or unwilling to voluntarily consent to treatment specifically related to his/her being gravely disabled as follows: (Note, if this box is checked, please also check box #1 under Imposition of Disabilities below). _________________________________________________ __________________________________________________________________. This person lacks capacity to give informed consent for routine medical treatment unrelated to remedying or preventing the recurrence of his/her being disabled as follows: (Note, if this box is checked, please also check box #2 under Imposition of Disabilities below). ___________________________________________________ __________________________________________________________________. Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15 CONFIDENTIAL MEDICAL INFORMATION Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com LPS CONSERVATORSHIP OF: CASE NUMBER Imposition of Disabilities: I make the following recommendations regarding the imposition of disabilities on the above named person: 1. Conservatee should not have the right to consent to treatment related specifically the Conservatee's being gravely disabled. 2. Conservatee should not have the right to consent to routine medical treatment unrelated to remedying or preventing the recurrence of the Conservatee's grave disability. 3. Conservatee should not possess a license to operate a motor vehicle. 4. Conservatee should not be allowed to enter into contracts in excess of $15.00. 5. Conservatee should not have the right to possess, have custody of, or control a firearm or any other deadly weapon because it would present a danger to the safety of the person or to others. 6. Conservatee should not have the right to vote because the Conservatee is not capable of completing an affidavit of voter registration. I declare that I am a physician, licensed in the State of California, OR a psychologist licensed in the State of California, who has a doctoral degree in psychology and at least five years of postgraduate experience in the diagnosis and treatment of emotional mental disorders. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (date): _________________ _______________________________ Printed Name __________________________ Signature (blue ink) I declare that I am a physician, licensed in the State of California, OR a psychologist licensed in the State of California, who has a doctoral degree in psychology and at least five years of postgraduate experience in the diagnosis and treatment of emotional mental disorders. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (date): _________________ _______________________________ Printed Name __________________________ Signature (blue ink) Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15 CONFIDENTIAL MEDICAL INFORMATION Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com