DECLARATION OF PHYSICIAN OR QUALIFIED LICENSED PSYCHOLOGIST CONSERVATORSHIP RE-EVALUATION Name: Address: Age: Sex: Birthdate: Case No.: ________________________________________ City, State, Zip: Date of Current Evaluation: Previous Diagnosis: INSTRUCTIONS FOR EVALUATION Please complete the following three areas of interest to assist us in making a decision as to whether the above-named person should continue to have a conservator. 1. Is there a mental disorder? Please give a diagnosis and explain the symptoms. 2. Can the individual provide for his or her basic needs (i.e., food, clothing, or shelter) in an unsupervised setting? Why do you feel he or she can or cannot? 3. Do you feel this individual is incapable or unwilling to accept voluntary treatment? I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (date): (SIGNATURE OF EVALUATOR) (SIGNATURE OF EVALUATOR) (TITLE) (TITLE) Approved for Optional Use L-0984b (Rev. March, 2014) DECLARATION PHYSICIAN OR QUALIFIED LISCENSED PSYCHOLOGIST EXHIBIT A www.occourts.org American LegalNet, Inc. www.FormsWorkFlow.com