LASC MH 004 Rev 11/18 For Optional Use SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES Reserved for Clerk222s File Stamp COURTHOUSE ADDRESS : PLA INTIFF/PETITIONER DEFENDANT/RESPONDENT Conservatorship Re-Evaluation Physicians Declaration CASE NUMBER N AME AND ADDRESS OF CONSERVATEE: AGE: DATE OF BIRTH: MALE FEMALE PREVIOUS DIAGNOSIS DATE OF EVALUATION Please LEGIBLY complete the following four areas of interest to assist the Judge in making a decision as to whether or not the above referenced person should continue to have a Conservatorship. 1. Is there a mental disorder? YES NO Please give a DIAGNOSIS and explain the symptoms in lay language. 2. Can individual provide for basic needs; food, clothing, shelter in an unsupervised setting? YES NO WHY? State facts in lay language. 3. Do you feel this individual is capable and willing to accept voluntary treatment? YES NO WHY? State facts in lay language. 4. Does this individual have the capacity of knowingly and intelligently accepting or refusing to accept prescribed medication? YES NO I declare under penalty of perjury, under the Laws of the State of California, that the foregoing is true and correct to the best of my knowledge. Executed on at, California (Date) (City) Signature of Evaluator Signature of Evaluator Printed Name of Evaluator Printed Name of Evaluator American LegalNet, Inc. www.FormsWorkFlow.com