SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re: ________________________________ An Adult 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) Stroke Alcohol/substance abuse 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): _____ _____ _______ _____ _____ _____ Chronic mental illness Head injury Dementia (e.g., Alzheimer's) If private home, please name any other persons living in the home and their relationship to the ward: ________________ Continue to live at current residence Change My plan is for the ward to: residence If changing residence, explain when, why and where ward will move: January 2014 ­ 906.10.v2 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? ________________ January 2014 ­ 906.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com III. Mental Health Treatment for the Ward 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 January 2014 ­ 906.10.v2 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. I do not plan to investigate because ____________________________________ ___________________________________________________________________ ___________________________________________________________________ VI. Other Information Does the ward have a prepaid funeral plan? (copy will be kept in a confidential file) No Yes, attach copy if not previously filed I don't know, please explain: Does the ward have a will? Yes No 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: ________________________________________________ January 2014 ­ 906.10.v2 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 (p