SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ CON _________ In re: ________________________________ An Adult REPORT OF CONSERVATOR OF PERSON I am the conservator of the person of the above named ward, and my report to the Court is as follows: 1. Reporting period: (insert dates) (The first date must be the date of appointment for the first report, and the ending date of the last report for all subsequent reports.) 2. Present age of ward: 3. Has the ward’s address changed? Praecipe. No Yes. Attached is a Change of Address State date of change: State reason(s) for change of residence: _____ Ward’s new address and telephone number are: _____ 4. Ward’s new residence is: Private home, owned by ward Private home, not owned by ward Conservator of person’s home Foster or boarding home Home of relative who is not the guardian (relationship) Group home (insert name) Nursing home (insert name) Assisted living facility (insert name) Hospital or medical facility (insert name) Other (please specify): (If ward lives with conservator of person, you may skip questions 5 and 6) 5. Date of personal visits with ward: July 2010 – 1003.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com 6. Were there any other contacts with the ward and/or staff at the ward’s facility (e.g., telephone contacts)? No Yes Explain: ________________________________ 7. During this reporting period the ward’s mental health has: Remained the same: Improved (describe): Deteriorated (describe): 8. During this reporting period the ward’s physical health has: Remained the same: Improved (describe): Deteriorated (describe): 9. During this reporting period, the ward’s professional health care team has changed as follows: Physician: Psychiatrist or psychologist: Social Worker or other case worker: Dentist: Podiatrist: Dietician: Therapist(s) (recreation, speech, physical, occupational): Other: 10. If ward does not reside in a facility, is the ward under a regular physician’s care? No Yes If no, explain: List doctor’s name, address, and telephone number: Date of last visit: 11. During this reporting period, was the ward hospitalized for any reason? No Yes Provide dates of hospitalization, facility, reason, and outcome: ______________________________________________________ 12. Have you participated in a care planning meeting during the reporting period? No Yes July 2010 – 1003.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com Provide date(s) of meeting(s): Explain goals established: 13. Does the ward have a current health care directive? No Yes If yes, attach copy if not previously filed (copy will be kept in a confidential location) If no, explain: 14. Has the ward participated in activities during this reporting period: Yes (describe): None available: Refuses or unable to participate: 15. I rate the ward’s living arrangement as: Excellent Average Below Average (explain): 16. I believe that the ward is: Content arrangement. If unhappy, explain why: Unhappy with living I don’t know. 17. I believe that the ward has the following unmet (physical, mental health, social, or basic) needs: ___________ What is being done to address these unmet needs? 18. In my opinion this conservatorship of the person continued. If not, explain: ______ ______ should be should not be ________________________________ 19.My powers should Remain the same Increase as follows: _____ July 2010 – 1003.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com Decrease as follows: _____ I wish to resign as conservator of the person. Attached is a Petition to resign. 19. Has conservator of person’s mailing address or telephone number changed during the reporting period? No Yes. Attached is a Change of Address Praecipe. 20. Conservator of person’s relationship to ward: Family Member (relation) Friend Member of Fiduciary Panel 21. I am also the conservator of the property I am not the conservator of the property, but I have handled the ward’s funds: a. Total amount received and source: _________________________________________________________ b. Total amount expended and for what purposes: ______________________________________________________ c. Balance currently in my possession or control and location: ______ I am not the conservator of the property and have not handled the ward’s funds. 22. Provide any other information that you feel the Court should know concerning the conservatorship of the person or the ward. (Note: If necessary, attach additional pages.): _____ 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 Person ______________________________________ Typed Name __________ Address (Actual address/not Post Office Box) July 2010 – 1003.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com __________ __________ 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 – 1003.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com