www.courts.ca.gov FOR COURT USE ONLY name(Name): (check all that apply): (date):(Complete item 5, then sign and file page 1 of this form.) (Complete items 6 through 8, sign page 3, and file pages 1 through 3 of this form.) (Complete items 6 and 8 of this form and complete form GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and file form GC-335A.)(If more than one item is checked above, sign the last applicable page of this form or, if item C is checked, form GC-335A. File page 1 through the last applicable page of this form; if item C is checked, file form GC-335A as well.) COMPLETE ITEMS 12264 OF THIS FORM IN EVERY CASE.(Name):(Office address and telephone number): (name):(date): (Complete a. or b.) (check all items below that apply) (see date in box in item A above). (date): (State facts in the space below or check this box and state the facts in Attachment 5.) (Practitioner may make ONLY the determination in item 5.) American LegalNet, Inc. www.FormsWorkFlow.com (Name): notimpressions(Instructions for items 6A2266C): Check the appropriate designation as follows: a = no apparent impairment; b = moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = i have no opinion.) American LegalNet, Inc. www.FormsWorkFlow.com (Name): (continued)(If so, complete remainder of item 6D.) (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.) (explain; continue on Attachment 6E if necessary): (Optional) eitheroror both(Declarant must initial here if item 7b applies: .) American LegalNet, Inc. www.FormsWorkFlow.com