SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re: ________________________________ An Adult REPORT OF GUARDIAN I am the guardian 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. State date of change: No Yes. Attached is a Change of Address _____ 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 Guardian's home 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 guardian, you may skip questions 5 and 6) 5. Date of personal visits with ward: (Note: Guardian is required to visit the ward at least once per month unless otherwise directed by court order. If more than six visits occurred during the November 2014 ­ 942.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com Foster or boarding home Home of relative who is not the guardian (relationship) reporting period, then you may choose to list one visit from each 30-day period for the last six months.) 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: ______________________________________________________ November 2014 ­ 942.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com 12. Have you participated in a care planning meeting during the reporting period? No Yes Provide date(s) of meeting(s): Explain goals established: No Yes 13. Does the ward have a current health care directive? 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 guardianship explain: should be should not be continued. If not, _________________________________________________ 19. I have been appointed: limited guardian general guardian November 2014 ­ 942.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com My powers should Remain the same Increase as follows: _____ Decrease as follows: _____ I wish to resign as guardian. A Petition Post Appointment is being filed separately. 20. Has guardian's mailing address or telephone number changed during the reporting period? No Yes. Attached is a Change of Address Praecipe. 21. Guardian's relationship to ward: Family Member (relation) Member of Fiduciary Panel 22. I am also the conservator I am not the conservator, 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 and have not handled the ward's funds. 23. Provide any other information that you feel the Court should know concerning the guardianship or the ward. (Note: If necessary, attach additional pages.): Friend ___________ 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. November 2014 ­ 942.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com ___________ Signature ______________________________________ Typed name __________ Address (actual address/not Post Office Box) __________ _____________________________________ __________ Telephone number __________ Email address _____________________________________ Bar number (if filer is an attorney) Subscribed and sworn to before me this 20______. day , Notary Public/Clerk CERTIFICATE OF SERVICE I certify that on the ____ day of ____________________, 20____, a copy of this filing was either eServed in accordance with the provisions of Administrative Order 13-15 or served by first class mail, postage prepaid, on the following persons (list names and complete mailing addresses): _______________________ Signature November 2014 ­ 942.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com