ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: Conservatorship of: PLACEMENT ASSESSMENT DETERMINATION* CASE NUMBER: *To be completed by conservator About the Conservatee: Name: _____________________________________ Age: ______ Date of Birth: ___________ Residence at commencement of conservatorship proceeding: _______________________________________________ _______________________________________________ own home/apartment skilled nursing home hospital If so, identify hospital: ________________________________ conservatee’s home/apartment board and care other (specify): _________________________________ How long has the conservatee been in the present residence? __________________ Current needs regarding level of care: requires total care able to care for himself/herself ambulatory urinary/bowel incontinence requires assistance with care has a feeding tube uses wheelchair/walker has a catheter The court has provided the conservator with the power to place the conservatee in a secured perimeter facility for the treatment of dementia. Optional Form SC-6015 [Rev. July 24, 2007] PLACEMENT ASSESSMENT DETERMINATION American LegalNet, Inc. www.FormsWorkflow.com CASE NUMBER: Insert Case Name: Conservatorship of: If the conservatee is residing at home, are care providers employed to assist him or her? Yes No If yes, identify the care providers: ______________________________________ employed through agency privately retained It is presumed that the personal residence of the conservatee at the time of commencement of the proceeding is the least restrictive appropriate residence for the conservatee. [Prob. C. § 2352.5] If the conservatee is currently living in his or her own personal residence: What measures would be necessary to keep the conservatee at home? Can the conservatee afford the measures described above? Yes No If the conservatee is living at a location other than his or her own personal residence at the commencement of the proceeding: Can the conservatee be returned to his or her own personal residence? Yes No If yes, what steps must be taken to accomplish this? If no, please describe the limitations or restrictions on a return of the conservatee to his or her own personal residence in the foreseeable future. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: Signed: Signature of Conservator Print Name: Optional Form SC-6015 [Rev. July 24, 2007] PLACEMENT ASSESSMENT DETERMINATION American LegalNet, Inc. www.FormsWorkflow.com