Ward’s Name:_______________________ Date of Plan __________________ Court File number ___________________ Date of Appointment ___________ Guardianship Plan Powers of Guardianship (Check all powers granted by the court.) 1. 2. 3. 4. 5. 6. 7. ____Custody of the ward/place of abode ____Care, comfort, and maintenance needs ____Care of personal property ____Medical care ____Contracts ____Supervisory authority ____Government benefits Custody and Abode: Do you foresee the need (at present or in the future) to establish a new abode? Please explain why? Is court approval required? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Note: A ward cannot be admitted to a regional treatment center by the guardian except, under commitment or for less than 90 days in a calendar year. Care, Comfort and Maintenance: Are there issues, or current needs regarding food, clothing, shelter, health, social or recreational requirements, training, education, habilitation or rehabilitation? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Care of personal effects: What personal effects (clothing, furniture, vehicles etc) need maintaining or supervision? Note: Per the statute the Guardian must give notice by mail to ward and interested persons prior to the disposal of the ward's clothing, furniture, vehicles, or other personal effects ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Medical Care: 1 American LegalNet, Inc. www.FormsWorkflow.com What types of medical conditions, treatments, counseling, or other services are needed? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Note: A ward cannot be admitted to a regional treatment center by the guardian except, under commitment, or for less than 90 days in a calendar year. Is there an existing Health Care Directive that provides instructions for medical care? Is there a named agent who needs to be consulted with or revoked? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are there any conscientious, religious, or moral beliefs or any other known perspective/attitudes the ward holds that would affect consent to medical treatments, counseling or other services etc? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Note: The guardian shall not consent to any medical care for the ward which violates the known conscientious, religious, or moral belief of the ward. The guardian shall not consent to electro convulsive therapy (ECT), sterilization, psychosurgery, or experimental treatment without further order of the court. Contracts: What types of contracts may need to be maintained, cancelled, or altered? If the guardian does not have the power of contract, who does? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Supervisory Authority: What types of restrictions do you foresee having to implement on behalf of the ward and why? ______________________________________________________________________________ ______________________________________________________________________________ Application of Government Benefits: If there is no current conservator, the guardian may need to apply for benefits. Are there any financial assistance programs that the ward may be eligible for? (Medicare A, B, D; Veteran’s Benefits, Food Stamps, MA, etc) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com General Are there areas of concern that need to be addressed and monitored in the ward’s functioning and/or their work, family, or social network? List ideas about how to address these complexities. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What hobbies or interests does the ward have? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Does the ward retain the right to vote? ______________________________________________________________________________ ______________________________________________________________________________ List any personal information pertaining to the ward that may impact your interactions with the ward and affect your planning for them. (e.g., religion, cultural perspectives, military background, history of abuse etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your short-term goals for the ward/guardianship? (e.g., move to/from SNF, arrange assisted living residence, address financial exploitation with adult protection, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your long-term goals for the ward? (e.g. work towards restoration to capacity, maintaining a safe home care plan, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com