SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re ________________________________ Ward GUARDIANSHIP PLAN This plan should be developed in consultation with the ward, family members when possible, and with input from any other community agencies involved in providing services to the person. I am the guardian of the above named ward and my proposed plan for providing services to the ward is as follows: Incapacity of ward (please select all that apply): Intellectual disability (e.g., MR) Chronic mental illness Head injury Stroke Alcohol/substance abuse Dementia (e.g., Alzheimer’s) Medical condition (describe): _____ Other: I. Living Arrangements for the Ward What is the current address of the ward’s residence? _____ ___________________________________________________________________ This is a Private home, owned by ward Private home, not owned by ward Guardian’s home Relative’s home (relationship) _____ Foster or boarding home Group home (insert name) Nursing home (insert name) _______ _____ Assisted living facility (insert name) Hospital or medical facility (insert name) Other (please specify): _____ _____ If private home, please name any other persons living in the home and their relationship to the ward: ________________ My plan is for the ward to: Continue to live at current residence Change residence If changing residence, explain when, why and where ward will move: 1 American LegalNet, Inc. www.FormsWorkFlow.com I do not have enough information at this time to change the ward’s current living arrangement. I have discussed the housing plan with the ward, and the ward agrees with this plan does not agree with this plan I have not discussed the housing plan with the ward because: _____ II. Medical Care for the Ward Describe the current physical health of the ward, including all known health conditions for which treatment is being received or is proposed: _____________________ I do not have enough information at this time to determine the ward’s medical needs. I plan to continue the medical services currently provided for the ward (provide name of health care professionals): Physician: Psychiatrist or psychologist: Social Worker or other case worker: _____ Dentist: Podiatrist: _____ Dietician: Therapist(s) (recreation, speech, physical, occupational): Other: I plan to seek a medical evaluation of the ward to determine the following: ___________________________________________________________ I believe the ward does not currently need treatment for any medical problems. Does the ward have a health care directive? Yes No, please explain: _____ In the absence of a health care directive, what efforts have you made to determine the ward’s preferred medical treatment? ________________ III. Mental Health Treatment for the Ward 2 American LegalNet, Inc. www.FormsWorkFlow.com Describe the current mental health of the ward, including all known diagnoses made by mental health professionals for which treatment is being received or is proposed: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ I do not have enough information at this time to determine the ward’s mental health treatment needs. I plan to continue the mental health services currently provided for the ward (provide name of health care professionals): Psychiatrist or psychologist: Social Worker or other case worker: _____ Other: I plan to seek a mental health evaluation of the ward to determine the following: ___________________________________________________________ I believe the ward does not currently need mental health treatment. IV. Social and Supportive Care for the Ward Describe the ward’s current social activities and support services: Is the ward currently employed? If yes, provide details: Yes No Is the ward currently participating in any educational, vocational or other training? Yes No If yes, provide details: In the next year, I plan to arrange the following services to assist the ward: Educational or training programs Vocational rehabilitation or supported work programs Medical treatment, operation, or procedure Mental health treatment Occupational, physical, or speech therapy Personal home care (e.g., home health aide) Case management or social work services Housing assistance and/or public benefits Assistive devices or accommodation Other (please specify): __________ V. Financial Care for the Ward Do you have control over any assets or funds of the ward? No Yes 3 American LegalNet, Inc. www.FormsWorkFlow.com I plan to investigate whether the ward has any type of insurance and whether the ward is eligible for any private benefits or government entitlements, including the following: Pension and/or income from employment Other benefits from past employers Social security benefits (disability, SSI, SSA retirement, SSA survivor benefits) Veteran’s benefits State benefits (food stamps, public assistance, TANF) Medicaid or Medicaid waiver Medicare Burial and funeral assistance Other: I do not plan to investigate because a conservator has been appointed. VI. Other Information Does the ward have a prepaid funeral plan? (copy will be kept in a confidential location) Does the ward have a will? Yes No Yes, attach copy if not previously filed No I don’t know, please explain: I don’t know, please explain: _____ Please provide the names and addresses of the ward’s next of kin: Spouse/domestic partner Children Grandchildren Parents Brothers and/or sisters Continue listing relatives below if no relatives are listed above. Nieces and/or nephews Uncles and/or aunts First cousins Grandparents Other kin Provide any other information that the Court should be aware of with regard to the guardianship plan for the ward: ________________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com I have consulted with the following person(s) in preparing this guardianship plan (check all that apply): Ward Family members of the ward Friends of the ward Care providers to the ward Ward’s attorney Others (please specify): VERIFICATION I being first duly sworn, on oath, depose and say that I have read the foregoing pleadings by me subscribed and that the facts therein stated are true to the best of my knowledge, information and belief. Signature of Guardian Address of Guardian City, State, Zip Code Telephone Number of Guardian E-mail Address of Guardian day Subscribed and sworn to before me this , Notary Public/Deputy 5 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on the______day of____________________20______, a copy of the foregoing Guardianship Plan was served by first class mail, postage prepaid, upon the following parties to the above captioned case and persons granted permission to participate pursuant to SCR-PD 303 and persons who requested notice pursuant to SCR-PD 304. Signature 6 American LegalNet, Inc. www.FormsWorkFlow.com