II-G Superior Court of the District of Columbia PROBATE DIVISION In re: Intervention Proceeding _________________________________ An Adult No. ____________________________ REPORT OF VISITOR I, ______________________________, Visitor appointed by Order entered on _________________________submit the following report concerning the investigation which I conducted pursuant to D.C. Code §21-2033 (c) and either §20-2041 (d) or §202054 (a) and Rule SCR-PD 327. I. Interview of Subject of Proceeding [Visitor should attempt to make the below inquiries in terms comprehensible to the subject]: A. Date and place of interview:_______________________________________________ __________________________________________________________ B. Oriented by time and place? _______ Yes ______ No C. Physical appearance: _____________________________________________ D. Subject asked and responded as follows: 1. Do you understand my explanation of the substance of the Petition; the nature, purpose and effect of the proceeding; and the general powers and duties of a guardian and conservator? ______Yes _________No (If no, explain here) 2. You have the right to retain an attorney at your own expense. If you cannot afford to pay an attorney, one will be provided by the Court without cost of you. Do you have an attorney? ____Yes ____No (If yes, give name and address:)__________________________________________________________ 3. Do you understand that under the law you have the following rights: To be present in person at any court proceeding and to see or hear all American LegalNet, Inc. www.FormsWorkflow.com evidence bearing on your condition; To be represented by counsel; ____Yes ____Yes ____No ____No To present evidence and cross-examine witnesses, including any court-appointed visitor or physician; ____Yes ____No To have a closed hearing on any issue; ____Yes ____No To contest the Petition ; ____Yes ____No To object to the appointment of the proposed guardian or conservator or their powers or duties; ____Yes ____No To object to the creation of the proposed guardianship or conservatorship or guardian ad litem appointed to represent your interests if the Court determines that a need for such representation exists; and ____No To have all or a portion of the compensation of any court-appointed visitor, attorney, guardian ad litem or physician paid by the Court or the Petitioner if you cannot afford to pay it? 1. ____Yes _____Yes ____No Who are your closest family members? (Give name, address and relationship)________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 5. Do you have a doctor? ________Yes ______No (If yes, give name and address)__________________________________________ ____________________________________________________________ Is this the same doctor who provided a letter (if any attached to the petition filed in these proceedings? ______Yes _______No 2 American LegalNet, Inc. www.FormsWorkflow.com 6. Do you need help caring for yourself or your finances ? _____Yes ____No (If yes, how?)____________________________ ________________________________________________________ 7. Who would you like to help care for you?_____________________ __________________________________________________________ 8. How are you currently caring for yourself?____________________ _________________________________________________________ _________________________________________________________ 9. Describe your income, assets and liabilities.___________________ _________________________________________________________ _________________________________________________________ 10. Do you know _____________________, the proposed Guardian or Conservator? ____Yes ____No a. How do you feel about having him/her make decisions about your day to day care?_____________________ b. What decisions do you want your guardian or conservator to make?______________________________________ c. If a guardian or conservator is appointed, what decisions would you like to make for yourself, and what actions (e.g. with respect to your property), would you like to take for yourself?______________________ _____________________________________________ _____________________________________________ d. How do you feel about what is requested in the petition? [Visitor should describe request] _____________________________________________ e. Names of third person(s) present during the interview (if any) and their relationship to the subject: ___________________________________________________ II. Interview of Person Seeking Appointed as Guardian or Conservator: A. Date and place of interview:______________________________ _____________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com B. Persons seeking appointment asked and responded as follows: 1. Name, address, home and business telephone numbers, and occupation: ____________________________________ _________________________________________________ 2. Relationship to subject of the proceeding:_______________ _________________________________________________ 3. Why does subject need help: ___________________________ __________________________________________________ 4. Where has the subject resided during the last three months? _______________________________________________ _______________________________________________ 5. Who, if anyone, has been caring for subject during this period? ___________________________________________________ ___________________________________________________ 6. What changes in residence are contemplated? _____________ __________________________________________________ 7. What alternative arrangements have you sought to assist subject?________________________________________ _______________________________________________ 8. Have you discussed your plans for care and management with subject? ____Yes ____No 9. III. Does subject agree with your plans? ____Yes ____No Interview of Persons Who Have Evaluated or Rendered Care, Counsel, Treatment or Service to Subject of Proceeding in Recent Past: A. Name and position of persons interviewed: ____________ __________________________________________________ B. Training and qualifications of person interviewed: ___________________________________________________ ___________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com C. Dates and types of evaluations of or care, counsel, treatment or services rendered to subject (attach additional sheets if necessary): __________/ __________ __________: __________/ __________ __________: __________/ __________ __________: D. Diagnosis or opinion of subject’s condition (if any) : ______________________________________________ ______________________________________________ E. What functions is the subject unable to perform in his or her daily life?_______________________ __________________________________________ IV. Report on Condition of Subject’s Present Place of Abode: A. Date______ [ ] visited [ ] information otherwise obtained : __________________________________ B. Address:________________________________ ___________________________________________ C. Type of Abode: ____________________________ D. Condition (if a home) Lawn and landscaping:___________________ 1. Exterior:______________________________ 2. Interior:_______________________________ a. Utilities working? ____Yes ____No b. Clean? ____Yes ____No c. Fire hazards? ____Yes ____No d. Other (explain): _____________________ V. Report on Condition of Subject’s Proposed Place of Confinement or Residence: A. Date __________ [ ] visited [ ] information otherwise obtained: _____________________________________ B. Location and type of place : ___________________________ ____________________________________________________ 5 American LegalNet, Inc. www.FormsWorkflow.com C. Condition:__________________________________________ ____________________________________________________ ____________________________________________________ VI. Conclusion of Visitor: A. The nature and degree of subject’s current incapacity or disability is as follows: ________________________ ___________________________________________ ___________________________________________ B. My evaluation of the fitness and appropriateness of the guardian or conservator seeking apointment is as follows:_______________________________________ _____________________________________________ _____________________________________________ _____________________________________________ C. I do [ ] I do not [ ] recommend limitations of the powers of the guardian or conservator seeking appointment. (If limitations recommend, explain)______________________________________ _____________________________________________ _____________________________________________ _____________________________________________ D. I am of the opinion that a guardian ad litem [ ] should [ ] should not be appointed to represent subject because ________________________________ _____________________________________________ VII. Additional comments (if any):_____________________ _____________________________________________ _____________________________________________ _____________________________________________ 6 American LegalNet, Inc. www.FormsWorkflow.com VIII. If there is no nominated guardian or conservator , I hereby nominate ________________________ to serve as guardian and __________________________ to serve as conservator, for the following reasons: ____________________________ _________________________________________________ _________________________________________________ _________________________________________________ Date ____________________________ ____________________________ Signature of Visitor 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 Form PD-1889H/Sep. 89 7 American LegalNet, Inc. www.FormsWorkflow.com