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Application For Mental Health Conservatorship Investigation Form. This is a California form and can be use in Los Angeles Local County.
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Tags: Application For Mental Health Conservatorship Investigation, California Local County, Los Angeles
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
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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
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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
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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
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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).
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#45 (LPS Referral)
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