CONNECTICUT PROBATE COURTS Assessment Team Report Guardianship of Person with Intellectual Disability PC-770 Rev. 1/18 CONFIDENTIAL Assessment Team Report /Guardianship of Person with Intellectual Disability PC - 770 Page 1 of 3 RECEIVED: Instructions: 1) Members of the Department of Developmental Services assessment team may use this form to make a report to the court in conjunction with 2) The report should be filed in the requesting court at appointment of 3)For more information, see C.G.S. sections 45a-674.4)Type or print the form in ink. Probate Court Name District Number In the Matter of (ame and present address) Respondent222s Date of Birth DDS Region Assessment Team Members ( job titles and telephone numbers.) . Date of Evaluation 2. Date of Evaluation The undersigned members of the assessment te Is the respondent a person with intellectual disability as defined in C.G.S. Section 1-1g? Is your conclusion supported by a psychological evaluation? Yes No Yes No Provide specific information1.A place of abode outside of the natural family home2. Specifically designed educational, vocational or behavioral programs . . American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Assessment Team Report Guardianship of Person with Intellectual Disability PC-770 Rev. 1/18 CONFIDENTIAL Assessment Team Report /Guardianship of Person with Intellectual Disability PC - 770 Page 2 of 3 3. The r elease 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 respondent222s capacity to meet essential requirements. Does the respondent need the support and protection of a guardian with respect to the management of finances? I f so , state the reasons for your opinion and provide specific examples. Pertinent History . American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Assessment Team Report Guardianship of Person with Intellectual Disability PC-770 Rev. 1/18 CONFIDENTIAL Assessment Team Report /Guardianship of Person with Intellectual Disability PC - 770 Page 3 of 3 Condition of the Respondent . Medications ( List any medications the respondent may be taking and the common side effects . ) Additional Comments . We 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 the respondent on the date listed above. Signature of Assessment Team Member Type Name Title Connecticut Professional License Number, if applicable Date Signature of Assessment Team Member Type Name Title Connecticut Professional License Number, if applicable Date American LegalNet, Inc. www.FormsWorkFlow.com