Level Of Care Determination Confidential General Plan Form. This is a California form and can be use in San Mateo Local County.
Tags: Level Of Care Determination Confidential General Plan, PR-22, California Local County, San Mateo
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address): Reserved for Clerk's Office Stamp TELEPHONE NO: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO Hall of Justice, Probate Division, 1st Floor 400 County Center Redwood City, CA 94063 CONSERVATORSHIP OF: PERSON ESTATE LIMITED CASE NUMBER: CONFIDENTIAL GENERAL PLAN HEARING DATE: Superior Court, County of San Mate requires the General Plan to be filed within ninety (90) days of appointment. If a question does not apply, write "not applicable" or "none." If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form. I. GENERAL PLAN Current address of conservatee Telephone Personal Caregiver: If the Conservatee has a personal caregiver, please state: Yes No. If so, is the family member(s) paid? Yes No Is the care provider a family member(s)? Yes No. If yes, what agency?___________________________________ Is the care provider(s) employed by an agency? Is the care provider(s) a private hire? Yes No Who prepares the caregiver's paychecks or payroll? (Wages, state & federal taxes, SDI, FICA, etc.)________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Describe conservatee's general medical condition: generally in good health generally in poor health has developmental disability has head injury has dementia has mental illness substance abuse issues (alcohol, drugs) How often does the conservatee see a doctor? ______________________Name of doctor? ________________________________ Any other health providers involved? dentist social worker podiatrist visiting nurse physical therapist speech therapist __________________________________________________________ __________________________________________________________ __________________________________________________________ hospice care worker psychiatrist/counselor other (specify)________________________________ Yes No. If yes, has the Is the conservatee being administered psychotropic medications for the treatment of dementia? Yes No. If not, contact your attorney or the Court granted the conservator "special dementia powers" as to medication? Court Investigator's Office. Page 1 of 3 Form adopted for Mandatory Use Local Court Form PR-22 [Rev September 2011] www.sanmateocourt.org CONFIDENTIAL GENERAL PLAN Local Court Rule 4.81.5 American LegalNet, Inc. www.FormsWorkFlow.com Is the conservatee placed in a secured perimeter or locked facility with no freedom of egress? Yes No. If yes, has the Court Yes No If not, contact your attorney or the Court granted the conservator "special dementia powers" as to placement? Investigator's Office. Activities (Describe the normal activities of the conservatee): School - Name: _________________________________________________________________________________________ Day Program - Name: ____________________________________________________________________________________ Employment - Name: _____________________________________________________________________________________ Conservatee unwilling to participate Conservatee unable to participate Visitation: How often do you visit the Conservatee?_________________________________________________________________________ Yes No. If yes, please explain who visits and the frequency of visits: Do family, friends or neighbors also visit? _________________________________________________________________________________________________________ Did conservatee express any end-of-life preferences in a California Advance Health Care Directive/Health Care Power of Attorney? Yes No. If yes, what are the expressed wishes? _____________________________________________________________ _________________________________________________________________________________________________________ II. FINANCIAL PLAN Yes No If yes, is it a revocable living trust Does the conservatee have a trust? Yes No Approximate current value: _______________ Has it been funded? Does the conservatee have a Representative Payee? Does the conservatee receive Medi-Cal benefits? Cal share of cost? $_____________________ Yes Yes a special needs trust No If yes, Name:___________________________ No If conservatee resides out of his/her home, what is the Medi- Estimated Monthly Income (to be completed by conservators of person or conservators of person and estate) Social Security/SSI $______________ Dividend Income $______________ Pension $______________ Rental Income $______________ Veteran's Benefits $______________ Interest Income $______________ Other (specify)______________________ Distributions from Trust $______________ Total estimated monthly income $_______________ Estimated Monthly Expenses LIVING EXPENSES (to be completed by conservators of person or conservators of person and estate) Rent or Mortgage $_________________________ Telephone/Cell $_________________________ Nursing/Care Home $_________________________ Utilities (PG&E, Water, Garbage, Cable TV, etc). $__________ Live-In Attendants $_________________________ Food $_________________________ Other Care Providers $_________________________ Transportation and gasoline $_________________________ Medical & Dental $_________________________ Laundry & Cleaning $_________________________ Medicines $_________________________ Medical & Dental Supplies $_________________________ Clothing $_________________________ Entertainment (subscriptions, recreation, etc.) $__________ Other: $_________________________ Total estimated monthly expenses $___________________ Other Expenses (to be completed by conservators of estate or conservators of person and estate) TAXES Income Property Payroll Current? Yes No Yes No Yes No Estimated amount $ _______________ $ _______________ $________________ Page 2 of 3 Form adopted for Mandatory Use Local Court Form PR-22 [Rev September 2011] www.sanmateocourt.org CONFIDENTIAL GENERAL PLAN Local Court Rule 4.81.5 American LegalNet, Inc. www.FormsWorkFlow.com INSURANCE Homeowners Renters Auto Health Life Other Company Premium Paid Yes No ____________________ Yes No ____________________ Yes No ___________________ Yes No ___________________ Yes No ____________________ Yes No ____________________ Coverage Amount ___________