ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-770 REV. 10/ STATE OF CONNECTICUT : RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF RESPONDENT'S DATE OF BIRTH Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [List both residence and domicile, if different.] DDS REGION ADDRESS Date of Evaluation ASSESSMENT TEAM MEMBERS [ List names, job titles, and telephone numbers.] 1. 2. The undersigned members of the Assessment Team state that they have personally examined or observed said respondent and hereby make their report as follows: Is the respondent a person with intellectual disability as defined in C.G.S. § 1-1g? Is your conclusion supported by a psychological evaluation? Yes Yes No No If "yes," please attach. Provide specific information regarding the severity of the intellectual disability of the respondent and those specific areas, if any, in which he or she needs the support and protection of a guardian, together with the reasons therefor. Complete all boxes (1-5), explaining whether or not the respondent has the ability to assure and/or consent to the following. If possible, provide specific examples. [1] A place of abode outside of the natural family home. [2] Specifically designed educational, vocational, or behavioral programs. [3] The release of clinical records and photographs. [4] Routine, elective and emergency medical and dental care. [5] Other specific services necessary to develop or regain to the maximum extent possible the ward's capacity to meet essential requirements. ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY Continued PC-770 American LegalNet, Inc. www.FormsWorkFlow.com PERTINENT HISTORY PHYSICAL CONDITION [Describe physical impairments, unless described in diagnosis above. List any medication the respondent may be taking and the common effects of such medication.] ADDITIONAL COMMENTS: We hereby certify that we were appointed by the Commissioner of the Department of Developmental Services or his or her designee, and we have personally observed or examined such respondent on the aforementioned date. SIGNED [Assessment Team Members (Include Connecticut Professional License Number, if applicable.)] Member 1 .................................................................................................................................... DATE: Print Name: Member 2 .................................................................................................................................... DATE: Print Name: [Use Second Sheet, PC-180, for additional members.] Note to Assessment Team Members: This form should be returned to the court at least three (3) days prior to the hearing. C.G.S. §45a-674. At any hearing for appointment of a plenary guardian or limited guardian of the person with intellectual disability, the court shall receive evidence as to the condition of the respondent, including a written report or testimony by a Department of Developmental Services assessment team appointed by the Commissioner of the Department of Developmental Services or his designee, no member of which is related by blood, marriage, or adoption to either the applicant or the respondent, and each member of which has personally observed or examined the respondent within forty-five days next preceding such hearing. The assessment team shall be comprised of at least two representatives from among appropriate disciplines having expertise in the evaluation of persons alleged to be persons with intellectual disability. The assessment team members shall make their report on a form provided for that purpose by the Office of the Probate Court Administrator and shall answer questions on such form as fully and completely as possible. The report shall contain specific information regarding the severity of the intellectual disability of the respondent and those specific areas, if any, in which he needs the supervision and protection of a guardian and shall state upon the form the reason for such opinions. . . . C.G.S. §45a-669(f). "Unable to meet essential requirements for his physical health or safety" means the inability through one's own efforts and through acceptance of assistance from family, friends, and other available private and public sources, to meet one's needs for medical care, nutrition, clothing, shelter, hygiene, or safety, so that, in the absence of a guardian of the person with intellectual disability, serious physical injury, illness, or disease is likely to occur. C.G.S. §45a-669(g). "Unable to make informed decisions about matters related to one's care" means the inability of a person with intellectual disability to achieve a rudimentary understanding, after conscientious efforts at explanation, of information necessary to make decisions about his need for physical or mental health care, food, clothing, shelter, hygiene, protection from physical abuse or harm, or other care. ASSESSMENT TEAM EVALUATION: GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC - 770 (Reverse) REV. 10/ American LegalNet, Inc. www.FormsWorkFlow.com