LOS ANGELES COUNTY – DEPARTMENT OF MENTAL HEALTH – OFFICE OF THE PUBLIC GUARDIAN APPLICATION FOR MENTAL HEALTH CONSERVATORSHIP INVESTIGATION (PLEASE TYPE OR PRINT) PG OFFICE USE ONLY PG Case #:___________________________________ T-CONS NEEDED BY: ____________________________ Assign To: ________________ WT. ______________ Screened By: ___________________________________ Comments: ____________________________________ I. PAGE 1 of 5 Send Original and one copy to: Office of the Public Guardian 320 West Temple St., 9th Floor Los Angeles, CA. 90012 OR FAX PER PROCEDURES (213) 974-0515 (General Info) “ 974-0509 (New Cases) (323) 226-2927 (County Counsel) (213) 687-4539 (Primary PG) “ 620-1405 (Back-up Fax #) (323) 225-8865 (Public Defender Fax #) REFERRING AGENCY OR FACILITY (Must be designated by County Mental Health) Name:__________________________________________________________ Date____________________ Street:______________________________________________________________Ward/Unit ____________ City:____________________________________________State:__________________ Zip:_____________ Telephone#( )_______ - __________ Contact Person ________________________________________ II. PATIENT NAME:___________________________________________ AKA:___________________________ First Middle Last Current Address:_________________________________________________________________ (Where the patient is now) Facility Name (if any) Number Street City:_____________________ State:_________ Zip: ___________ Tel # ( )_________ - _________ Home Address:___________________________________________________________________ Faciltiy Name (if any) Number Street City:_____________________ State___________ Zip__________ Tel #( )_______ - _________ Age:_____ Birthdate_________ Birthplace_________________ Sex:______ Race/Ethnicity________________ Religion:______________ SSN:____________ Marital Status________ Co. Mental Health MIS#____________ Education Level__________________ Veterans? Yes _____ NO ________V.A. #________________ Last or Usual Occupation:___________________________________________________________________ Medi-Cal #:_________ Medicare #:___________ Driver License#____________ State:______ Expires________ Height:____________ Weight:_________________ Hair Color:______________ Eyes Color:____________ Charges:_________Booking#____________Criminal Case #:___________ Criminal Dept #_______________ Court Date: ________ Maximum Commitment Date:___________Date Declared Incomptent:_____________ #45 (LPS Referral) Confidential Patient Information – See Welfare & Institutions Code 5328 American LegalNet, Inc. www.FormsWorkflow.com LOS ANGELES COUNTY – DEPARTMENT OF MENTAL HEALTH – OFFICE OF THE PUBLIC GUARDIAN APPLICATION FOR MENTAL HEALTH CONSERVATORSHIP INVESTIGATION PATIENT NAME:____________________________________ (PLEASE TYPE OR PRINT) PARTNERS ISA, SPOUSE, RELATIVES, FRIENDS, LANDLORD, SIGNIFICANT OTHERS III. RELATION NAME ADDRESS Page 2 of 5 TEL # 1. 2. 3. 4. IV. INCOME (List all known or possible sources of income) SOURCE PAYEE MONTHLY AMT ____ Social Security/SSI ________________________________ __________________ ____ Veterans Comp/Retirement ________________________________ __________________ ____ Other Specify____________ ________________________________ __________________ ____ Other Specify____________ ________________________________ __________________ V. ASSETS [ ] Real Property [ ] Furniture [ ] Car/Motor Vehicle [ ] Mobile Home [ ] Bank Account(s) [ ] Life Insurance [ ] Stocks/Bonds/Notes [ ] Other (Specify):___________________________________________________________________________ Describe all known assets: ITEM LOCATION OR ID# VALUE (If known) 1._____________________________________________________________________________ 2.__________________________________________________________________________________________ 3.__________________________________________________________________________________________ 4.__________________________________________________________________________________________ 5.__________________________________________________________________________________________ Remarks (If any)_____________________________________________________________________________ ____________________________________________________________________________________________ #45 (LPS Referral) Confidential Patient Information – See Welfare & Institutions Code 5328 American LegalNet, Inc. www.FormsWorkflow.com LOS ANGELES COUNTY – DEPARTMENT OF MENTAL HEALTH – OFFICE OF THE PUBLIC GUARDIAN DECLARATION IN SUPPORT OF LPS CONSERVATORSHIP PLEASE TYPE OR PRINT Page 3 of 5 VI. PATIENT _________________________Facility/Agency__________________________________ 72 Hr. Hold date______________ 14 Day Cert. Eff. Date____________* 30 Day Cert. Eff. Date___________ *Note: No T-Cons. will be granted on 30 day certs. Application must be received by PG with a minimum of 25 days remaining on the 30 day certification. IS PATIENT CURRENTLY IN AN INTENSIVE TREATMENT FACILITY? Yes [ ] No [ ] Penal Code No._______________________ Exp. Date_________________ (If no – I hereby certify that further examination on an in-patient basis is not necessary for a determination that this patient is gravely disabled). I am recommending conservatorship for the above-referenced person. I believe he or she is not able to provide for his or her personal needs for food, clothing, or shelter as a result of a mental disorder and is: [ ] Unwilling or [ ] Unable to accept voluntary treatment. Diagnosis:_________________________________________________________________________________ DSM IV Classification number____________________________ Specific facts or incidents that demonstrate the patient is gravely disabled and is unwilling or unable to accept voluntary treatment: (Attach additional documentation if necessary)__________________________________ Yes [ ] No [ ] Does the patient have the capacity to complete an affidavit of voter registration and register to vote? Yes [ ] No [ ] The patient’s privilege of possessing a license to operate a motor vehicle should be revoked. Reasons:_________________________________________________________________________________ Yes [ ] No [ ] Would the possession of a firearm or other deadly weapon by the patient present a danger to his or her safety or to other persons? Reasons:_________________________________________________________________________________ VII. I declare under penalty or perjury that the foregoing is true and correct and I recommend a temporary Conservatorship. Excuted on Date:_______________________ at ____________________________, California ________________________________ Signature of Professional Evaluator ________________________________ PRINT OR TYPE NAME & TITLE ___________________________________________________ Signature of Physician in charge of Facility or his/her designate ________________________________ PRINT OR TYPE NAME & TITLE NOTE: Treating physician may be required to testify in Court. #45 (LPS Referral) Confidential Patient Information – See Welfare & Institutions Code 5328 American LegalNet, Inc. www.FormsWorkflow.com LPS CONSERVATEE INITIAL TREATMENT PLAN Date: ________________________ Page 4 of 5 Facility: ________________________________ Name: ________________________________ DOB: ____________ SSN: __________________________ (Last) (First) Participants: ___ Consumer, ___ Family Member, specify___________________Other, specify_____________ Principle Diagnosis (DSM IV) related to Grave Disability:_____________________________________GAF: ___ Refer to instructions on reverse side in order to complete the table below. v Treatment Goals Initial Target Interventions Assess cognitive function Assess emotional issues Assess physiologic dysfunction contributing the psych Assess social/occupational function *Decrease aggressiveness/homicidal ideation *Decrease agitation Decrease anxiety Decrease antisocial behavior Decrease conversion symptoms Decrease depression Decrease dissociative symptoms Decrease eating problems Decrease enuresis and encopresis Decrease family discord Decrease hypochondriacal symptoms Decrease insomnia or parasomnia Decrease interpersonal problems *Decrease mania Decrease marital discord Decrease motor tics Decrease obsessions and/or compulsions Decrease panic attacks Decrease phobias Decrease post-traumatic symptomatology *Decrease psychosis Decrease sexual dysfunction Decrease social and/or occupational dysfunction Decrease somatization symptoms *Decrease specific impulse/general impulsivity Decrease substance abuse or dependence *Decrease suicidal thoughts/self-destructiveness *Improve self-maintenance (Activities of Daily Living) Prevent relapse of anxiety disorders Prevent relapse of bipolar disorder Prevent relapse of major depression Prevent relapse of schizophrenia Other (Specify) * Goals related to reduction of grave disability Recommended discharge setting: ___ Home, ___ Assisted Living, ___ Open Residential, ___ Locked Residential Planned Review Date: ________________ Clinician Signature & Licensure:_________________________ #45 (LPS Referral) LOS ANGELES COUNTY – DEPARTMENT OF MENTAL HEALTH American LegalNet, Inc. www.FormsWorkflow.com OFFICE OF THE PUBLIC GUARDIAN Page 5 of 5 PATIENT NAME:______________________________________________________________________ (PLEASE TYPE OF PRINT) REMARKS: (Use this page for additional remarks or information identify section additional documentation may be attached). ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ #45 (LPS Referral) American LegalNet, Inc. www.FormsWorkflow.com