DECLARATION PHYSICIAN’S OR QUALIFIED LICENSED PSYCHOLOGIST’S CONSERVATORSHIP RE-EVALUATION Name: _________________________________________ Case No.:__________________________________LPS Address: ______________________________ City, State, Zip: _________________________________________ Age: _______ Sex: _______ Birthdate: ____________ 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) LPS-2 [New July 1, 1987] 984 (R3/09) (TITLE) DECLARATION EXHIBIT A MIS 3CR American LegalNet, Inc. www.FormsWorkflow.com