MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 1 STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services 200 South G Street Madera, CA 93637 PH#: (559)416-5560 FAX#:(559)673-8216 INITIAL CONSERVATORSHIP CONSERVATORSHIP TERMINATION COURT CASE#: FCS#: NEXT COURT DATE: NOTE: INVESTIGATION FEE OF $400 IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT SECTION 1: CONSERVATOR/ PETITIONER222S INFORMATION N AME (Last, First, Middle ) RELATIONSHIP TO CONSERVATEE : MAIDEN NAME : OTHER NAMES KNOWN BY: DATE OF BIRTH : PLACE OF BIRTH : ATTORNEY NAME / TELEPHONE # / FAX # : HOME TEL. # : CELL TEL. # : E - MAIL ADDRESS: STREET ADDRES S : SOCIAL SECURITY # : DRIVER222S LICENSE # / STATE : CITY : STATE : ZIP CODE : HOW LONG AT THIS ADDRESS ? YEARS: MONTHS: SECTION 2 : CONSERVATEE I NFORMATION NAME (Last, First, Middle ) CURRENT MEDICAL DIAGNOSES: DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # : TEL. # : PHYSICIANS NAMES AND TELEPHONE NUMBERS : STREET ADDRES S : SOCIAL SECURITY # : DOES THE CONSERVATEE HAVE A CAPACITY DECLARATION? Yes No CITY : STATE : ZIP CODE : HOW LONG AT THIS ADDRESS ? YEARS: MONTHS: SECTION 3 : OBJECTING WITNESS INFORMATION N AME (Last, First, Middle ) RELATIONSHIP TO CONSERVATEE : MAIDEN NAME : OTHER NAMES KNOWN BY: DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # : HOME TEL. # : CELL TEL. # : E - MAIL ADDRESS: STREET ADDRES S : SOCIAL SECURITY # : DRIVER222S LICENSE # / STATE : CITY : STATE : ZIP CODE : HOW LONG AT THIS ADDRESS ? YEARS: MONTHS: CONSERVATORSHIP INVESTIGATION INTAKE/QUESTIONNAIRE Revis ed February 2019 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 2 SECTION 4 : CONCERNS AND PROPOSALS 1. Reasons for or against the Conservatorship : a. Petitioners: What are the circumstances that lead to your decision to petition for Conservatorship or a change to the current Conservatorship? b. Objecting Witness: What are the top three reasons why the Conservatorship should not be granted? c. Is there currently a temporary Conservatorship in place? Yes No d. What is the Conservatee222s usual routine, including times for wake-up, meals, bath, recreation, sleep, work, and attendance at any programs? e. Please summarize your plans for the Conservatee. Include plans for the daily care, support, supervision and control of the Conservatee regarding health, education, religion, and recreation: f. How often will you be able to visit the Conservatee if the Conservatee is placed in a care facility? g. If home care is the option used, will other family members and friends be able to visit the Conservatee on a regular basis? Yes No What are the best days and hours for visitors? American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 3 SECTION 5 : INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: Full n ame: Date of birth: Social Security # : Other names used: Driver222s l icense #/ State: Date relationship b egan: Home phone number: Cell phone number: Occupation: Present e mploy er: Employer222s p hone #: Days/Hours worked: SECTION 6 : EDUCATION AND EMPLOYMENT A. Education Level : Please list the highest grade or level of schooling you completed: GED High school graduate College courses taken College graduate Post graduate work 1. Are you currently employed? Yes No 2. IF YES, what is your occupation, employer222s name, telephone number and employer222s address? 3. How long have you been with your current employer? Years: Months: 4. Current workdays and hours (please list what time you start work and what time you end work each day) : SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 5. Please list your employment history over the past 5 years: D ates of employment : Name of e mploy er : Telephone # : Occupation : Reason for leaving : 6. Who takes care of the Conservatee wh en you are unavailable? Please pr ovide their names/telephone #222s: SECTION 7 : MENTAL HEALTH HISTORY 1. Have you ever been in counseling or therapy? Yes No IF YES, please list in chronological order (by year) the therapists, counselors, clergy and/or marital counselors who you have gone to: Date : Doctor/Therapist n ame : Complete mailing a ddress : Telephone # : 2. Have you ever been hospitalized for psychiatric treatment? Yes No (see next page if yes) American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 4 IF YES, please list hospitals or clinics attend and the dates of treatment: Date : Hospital n ame : Complete mailing a ddress : Telephone # : 3. Have you ever taken psychiatric medication? Yes No (for example, for depression, anxiety, etc.) IF YES, please list the names of all medications and the name, telephone number and the complete mailing address of the physician who prescribed the medication. 4. Has the Proposed Conservatee ever been in counseling/therapy or hospitalized for psychiatric treatment? Yes No IF YES, please list the therapist, agency or hospital that provided the services and the dates of treatment. 5. P lease list the names of all of the Conservatee222s medications and the name, telephone number and the complete mailing address of the physician who prescribed the medication: SECTION 8 : ALCOHOL AND SUBSTANCE ABUSE HISTORY 1. What kind(s) of alcohol do you drink? 2. How often do you drink? 3. Has your drinking ever been an issue between you and your family or friends? Yes No 4. Are you currently in or have you ever received treatment for alcohol abuse? Yes No If yes, please check all applicable treatment: Counseling/Therapy Detox Rehab Inpatient Rehab Outpatient AA/NA 5. If a box was checked, please list, in chronological order, the therapist/agency/hospital utilized: Date : Therapist/Hospital : Complete mailing a ddress : Tel # : 6. Drug u se history: Name of d rug : How o ften : Age of first u se : Date of last u se : 7. Prescription drug u se history: Name of d rug / # milligrams: How o ften taken: Prescribing d octor: Doctor222s phone n umber: 8. Do you have a medical marijuana card? Yes No Expiration Date: 9. Have drugs or alcohol ever caused you to lose a job? Yes No American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 5 SECTION 9 : Y OUR RELATIONSHIP WITH THE CONSERVATEE 1. Please describe the Conservatee (check off those that apply ) : a. Activity level: high energy low energy b. Attention: able to focus easily distracted c. Level of intensity when upset: reacts dramatically becomes quiet d. Gets hungry or tired: at predictable times at unpredictable times e. Response to stimulation: startles easily to sounds remains calm f. Appetite: picky eater will eat anything g. Adaptability: approaches new situations easily takes a long time to become comfortable h. When faced with obstacles (for ex: putting together a puzzle): is patient gives up easily i. Mood in general: the Conservatee is positive and happy the Conservatee focuses on the negative 2. What does the Conservatee do well? 3. What kinds of problems does the Conservatee have (Social, emotional, intellectual)? 4. What have you done to try to help the Conservatee with these problems? SECTION 10 : YOUR FAMILY BACKGROUND AND OTHER INFORMATION 1. What are/were your parents222/stepparents222 names and occupations? 2. What are your siblings222 names? What place are you in the birth order? 3. Who lived with you growing up? What role did they play in your life? 10. Has your drug use ever been an issue between you and your family and friends? Yes No 11. Have you ever been court ordered for drug testing? Yes No IF YES, When? 12. Were the results of the drug tests positive? For what drugs? American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0006 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 6 4. What was the quality of your parents222 relationship with each other growing up? What is it like no