SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ CON _________ In re: ________________________________ An Adult PLAN OF CONSERVATOR OF PERSON 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 conservator of the person of the above named ward and my proposed plan for providing services to the ward is as follows: I. Living Arrangements for the Ward My plan is for the ward to: Continue to live at current residence residence If changing residence, explain when, why and where ward will move: Change 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 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. III. Mental Health Treatment for the Ward _____ _____ July 2010 ­ 1004.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com 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 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 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. I do not plan to investigate because another person has been appointed as conservator of the property. I do not plan to investigate because ____________________________________ ___________________________________________________________________ ___________________________________________________________________ VI. Other Information Provide any other information that the Court should be aware of with regard to this plan for the ward: _____________________________________ ________________________________________________________________ I have consulted with the following person(s) in preparing this plan (check all that apply): Ward Family members of the ward Friends of the ward Care providers to the ward July 2010 ­ 1004.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com 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 conservator of the person __________ Address (Actual address/not Post Office Box) __________ __________ Telephone number __________ E-mail address (optional) Subscribed and sworn to before me this 20______. day , Notary Public/Clerk 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, to the following persons (list names and addresses of all parties): ____________________________________ Signature July 2010 ­ 1004.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com