CONFIDENTIAL SDSC PR-020 (Rev. 8/13) REFERRAL INFORMATION AND LIST OF RELATIVES Prob. Code 247 1826 (CONFIDENTIAL) Page 1 of 2 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE., SAN DIEGO, CA 92101 CONSERVATORSHIP OF P ERSON E STATE L IMITED CONSERVATORSHIP OF JUDGE/DEPT APPOINTMENT ACCOUNTING OTHER HEARING DATE REFERRAL INFORMATION AND LIST OF RELATIVES (CONFIDENTIAL) CASE NUMBER TO BE COMPLETED BY THE PETITIONER 1. (Proposed) Conservatee: Name: Address: (Gate/Door Code): Zip Code: Tel. No.: Contact Person: Is there an LPS conservatorship? Yes No (If yes, list case number, name & address of LPS conservator) Is (proposed) conservatee a Medi-Cal recipient? Yes No 2. Information for the Court Investigator (to be completed by the petitioner): A. Special Circumstances: Primary language s English Spanish other: Communication issues: non-verbal aphasia other: Any other barriers to investigation/meeting with the conservatee that the investigator should be aware of: B. Safety/Hazards: health hazards paranoia unpredictable aggressive threatening behavior other: firearms dogs drugs gangs restraining orders (list case number and court location): 3. Name of facility or program: This section is to be completed if the conservatee is always or frequently at another location between the hours of Name: Type of Facility/Program: Address: Zip Code: Tel. No.: Contact Person: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL SDSC PR-020 (Rev. 8/13) REFERRAL INFORMATION AND LIST OF RELATIVES Prob. Code 247 1826 (CONFIDENTIAL) Page 2 of 2 CONSERVATORSHIP OF (Name): CASE NUMBER 4. (Proposed) Conservator: Name: Relationship: Address: Zip Code: Tel. No.: Work: Fax: Cell No.: 5. (Proposed) Conservatee222s Physician/General Practitioner: Name: Institution (if applicable): Address: Zip Code: Tel. No.: Fax: 6. (Proposed) Conservatee222s Attorney: Name: Relationship: Address: Zip Code: Tel. No.: Work: Fax: Cell No.: LIST OF CONSERVATEE222S RELATIVES/FRIENDS: List conservatee222s spouse or registered domestic partner, 1st degree relatives (parents and children), 2nd degree relatives (brothers and sisters, grandparents and grandchildren), neighbors, and, if known, conservatee222s close friends. Name: Relationship: Address: Zip Code: Home Tel. No.: Work Tel No.: See attachment for additional relatives/friends. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Type or Print Name Signature of Petitioner American LegalNet, Inc. www.FormsWorkFlow.com