SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION IN RE: ______ INT ______________ __________________ An Adult ______ IDD ______________ PETITION FOR APPOINTMENT OF TEMPORARY GUARDIAN Emergency Guardian for up to 21 day period based upon life threatening situation or situation involving emergency care where no other person appears to have authority to act under the circumstances Health Care Guardian for up to 90 days where there is no guardian, where there are two certifications of incapacity under D.C. Code, sec.21-2204 and where no other person appears to have authority to act under the circumstances Provisional Guardian for up to six months based upon finding that any guardian is not effectively performing his or her duties and that the welfare of the ward requires immediate action Extension of appointment of an Emergency Guardian to serve as Health Care Guardian Extension of appointment of a Health Care Guardian for an additional 90 days 1. __________________________________________________ Name of petitioner _______________________________________________________ Address of petitioner _______________________________________________________ Telephone number of petitioner _______________________________________________________ Petitioner’s relationship to subject of the proceeding 2. ______________________________________ __________ Name of alleged incapacitated person Age ____________________________________________________ _________________________________________________________ _________________________________________________________ Residence of alleged incapacitated person 3. This Court has jurisdiction because: The alleged incapacitated person is physically present in the District of Columbia or is domiciled in the District of Columbia. American LegalNet, Inc. www.FormsWorkflow.com 4. (a) The appointment of an emergency guardian is necessary because there is no guardian, no other person appears to have authority to act under the circumstances and a life threatening situation or situation involving emergency care exists: (1) if a life threatening situation, please state the nature of the life threatening situation ___________________________ __________________________________________________ ________________________________________________ ; or (2) if a situation involving emergency care (meaning immediate treatment, including diagnostic treatment, provided in response to a sudden, acute and unanticipated medical crisis in order to avoid injury, extreme pain, impairment, or death), please state the nature of such situation involving emergency care: _________________________________________________ _________________________________________________ (b) The appointment of a health care guardian is necessary because there is no guardian and the incapacity of the proposed ward has been certified pursuant to D. C. Code, sec. 21-2204 by two professionals, one of whom is a physician and one of whom is a qualified psychologist or psychiatrist and one of whom has made the examination within 1 day preceding certification; or (c) The appointment of a provisional guardian is necessary because the guardian is not effectively performing his or her duties and the welfare of the ward requires immediate action. The name, address and telephone number of the existing guardian is as follows: ________________________________________________________ The length of time for which a provision guardian is sought is: _____ (d) The extension of the appointment of an emergency guardian is sought, requesting that hereafter the emergency guardian serve as health care guardian (e) The extension of the appointment of a health care guardian is sought for an additional 90 days based upon the continued incapacity of the subject of this proceeding and the continued need to provide substituted consent in accordance with D. C. Code, sec. 21-2210 for any health care service, treatment or procedure or based upon the filing of a petition for limited or general guardian prior to the expiration of the appointment of the health care guardian which has not yet been heard by the Court. American LegalNet, Inc. www.FormsWorkflow.com 5. The alleged incapacity of the subject of this proceeding does does not arise out of mental retardation. 6. For requests for an emergency guardian or health care guardian, Petitioner has attached two certifications of incapacity in accordance with D. Code, sec. 21-2204 and requests that the appointment of an examiner be waived; or Petitioner has not attached two certifications of incapacity in accordance with D. C. Code, sec. 21-2204, and an examiner must be appointed; or Petitioner has filed the certificates of incapacity and requests appointment of an examiner. 7. (a) (b) Petitioner requests the appointment of a Guardian Ad Litem for the subject of the proceeding for the following purposes: To assist the subject to determine his or her own interests in regard to this proceeding To determine the interests of the subject of the proceeding because the subject is unconscious or otherwise wholly incapable of determining his or her interest in this proceeding even with assistance. Appointment of a Guardian Ad Litem is not necessary. 8. If there is any person who otherwise appears to have authority to act under the circumstances, please provide a detailed explanation of why appointment of either an emergency guardian or health care guardian is being sought by the petitioner: _________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 9. Listed below are the names, addresses and telephone numbers of the persons to whom notice will be send pursuant to SCR-PD 325: _________________________________________________________________ Name of Subject of the Proceeding _________________________________________________________________ Spouse or domestic partner or if none and adult child(ren) or if none parents or if none adult sibling _________________________________________________________________ If none of the above, at least one of the nearest adult relatives if such person can be found American LegalNet, Inc. www.FormsWorkflow.com _________________________________________________________________ Any person serving a guardian or conservator or who has care and custody of the subject _________________________________________________________________ Any counsel known to petitioner _________________________________________________________________ Persons nominated in subject’s durable power of attorney to be guardian and conservator __________________________________________________________________ Any previously appointed guardian or conservator 10. Petitioner seeks the appointment of an emergency or health care guardian with the following powers: All powers under D.C. Code, sec. 21-2047.02, including The power to grant, refuse, or withdraw consent to medical examination and health care treatment for which the individual has been deemed incapacitated pursuant to D. C. Code, sec. 21-2204; The power to obtain medical records for the purposes of providing substituted consent pursuant to D. C. Code, sec. 212210; The power to exercise the status of a legal representative under Chapter 12 of title 7. For a health care guardian only and in the absence of a durable power of attorney for health care, all powers under D. C. Code, sec. 21-2210, including The power to grant, refuse or withdraw consent on behalf of the patient with respect to the provision of any health-care service, treatment or procedure; and/or Certain enumerated powers as follows: ___________________ ___________________________________________________________ ___________________________________________________________ For a provisional guardian, petitioner seeks the appointment of: (if specific appointment sought) __________________________________________ Name _________________________________________ Address ________________________________________ Telephone number American LegalNet, Inc. www.FormsWorkflow.com VERIFICATION I, ____________________________, being first duly sworn on oath or (or I, __________________________________________, affirm), depose and say that I have read the foregoing pleadings by me subscribed and that the facts stated therein are true to the best of my knowledge, information and belief. _____________________________________ Signature of Petitioner Subscribed and sworn to before me this _____ day of _______________, 20__. CERTIFICATE OF SERVICE I hereby certify that on the ___ day of ____________, 20__, a copy of the foregoing 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 of Petitioner _________________________________________________________________ Counsel for Petitioner _________________________________________________________________ Address, Telephone Number and Bar Number American LegalNet, Inc. www.FormsWorkflow.com SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION IN RE: _______ INT ____________ __________________ An Adult ________ IDD ____________ ORDER APPOINTING TEMPORARY GUARDIAN Upon consideration of the Petition for Appointment of Temporary Guardian filed on the ____ day of ____________________, 20__, by ___________________________, it is by the Court this ________ day of _______________, 20___, ORDERED, That upon a finding that ____________ is an incapacitated person for whom there is no guardian in place, that no other person appears to have authority to act under the circumstances and that a life-threatening situation or a situation involving emergency care exists within the meaning of the District of Columbia Guardianship, Protective Proceedings, and Durable Power of Attorney Act of 1986, as amended by the Health-Care Decisions for Persons with Developmental Disabilities Act, ____________________________ be and hereby is appointed as emergency guardian for _____________________________ for a period not to exceed 21 days from the date of this order; ORDERED, That upon a finding that there is no guardian in place, that no other person appears to have authority to act under the circumstances and that _________________ has been found to be an incapacitated individual for health care decisions within the meaning of the Health-Care Decisions for Persons with Developmental Disabilities Act, and two certifications of incapacity have been presented to the Court in accordance with D. C. Code, sec. 21-2204, ________________________ be and hereby is appointed as health care guardian for _______________________ for a period not to exceed 90 days from the date of this order; ORDERED, That upon a finding that a guardian is in place but the guardian is not effectively performing his or her duties and the welfare of the ward requires immediate action, ______________________________ be and hereby is appointed as provisional guardian for a period not to exceed six months from the date of this order and the authority of the permanent guardian previously appointed by the Court, _________________, is suspended for as long as the provisional guardian has authority; ORDERED, That the authority of ______________ as emergency guardian be and hereby is extended for a specified period until ____________ (such period not to exceed 90 days) by authorizing the emergency guardian to serve as a health-care guardian within the meaning of the Health-Care Decisions for Persons with Developmental Disabilities Act; American LegalNet, Inc. www.FormsWorkflow.com ORDERED, That (A) upon a determination of continued incapacity and continued need for the provision of substituted consent for any health-care service, treatment, or procedure pursuant to D. C. Code, sec. 21-2210 or (B) upon a determination that a petition for a permanent limited guardian or general guardian has been filed pursuant to D. C. Code, sec. 21-2041, prior the expiration of the appointment of the temporary guardian but has not yet acted upon by the Court, the appointment of __________________ as health-care guardian be and hereby is extended for one additional period of up to 90 days; ORDERED, That the emergency or health-care guardian shall have the powers and duties set forth in D. C. Code, secs. 21-2047.01 and 21-2047.02, and shall (A) become or remain personally acquainted with the ward and maintain sufficient contact with the ward to know of the ward’s capacities, limitations, needs, opportunities, and physical and mental health; (B) make decisions on behalf of the ward by conforming as closely as possible to a standard of substituted judgment or, if the ward’s wishes are unknown and remain unknown after reasonable efforts to discern them, make the decision on the basis of the ward’s best interests as that term is defined by the Health-Care Decisions for Persons with Developmental Disabilities Act; (C) encourage the ward to participate with the guardian in the decision-making process to the maximum extent of the ward’s ability in order to encourage the individual to act on his or her own behalf whenever he or she is able to do so, and to develop or regain capacity to make decisions in those areas in which he or she is in need of decision-making assistance, to the maximum extent possible; and (D) make any report the Court requires; and it is further ORDERED, That the Court further grants the emergency or health-care guardian the power to: Grant, refuse, or withdraw consent to medical examination and health-care treatment for which the individual has been deemed incapacitated pursuant to D. C. Code, sec. 21-2204; Obtain medical records for the purpose of providing substituted consent pursuant to D. C. Code, sec. 21-2210; Have the status of a legal representative under Chapter 12 of Title 7; and it is further ORDERED, That the power of any emergency, health-care or provisional guardian shall be limited as provided by D. C. Code, sec. 21-2047.01; and it is further ORDERED, That in the absence of a durable power for health care and based upon the certification of incapacity in accordance with D. C. Code, sec. 21-2204, the powers of ___________ as health-care guardian shall include the power grant, refuse or withdraw consent on behalf of the patient with respect to the provision of any health-care service, treatment, or procedures in accordance with D.C. Code, sec. 21-2210; and it is further American LegalNet, Inc. www.FormsWorkflow.com ORDERED, That the powers of the emergency, temporary or provisional guardian shall be limited to the following enumerated powers: ________________________________________________________________________ ________________________________________________________________________ ; ORDERED, That bond is set in the amount of $________; and it is further ORDERED, _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ SO ORDERED. ____________________________________ Judge cc: American LegalNet, Inc. www.FormsWorkflow.com