251 2018 Nevada Supreme Court Page 1 of 10 226 Annual Report of Guardian (Adult) COURT CODE: 1125 Guardian222s Name: Street Address: City, State, Zip: This is a new address: yes / no Phone: home / cell / work Email: Self-Represented IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE In the Matter of the Guardianship of the: Person Person and Estate of: ( name of person who has a guardian) A Protected Person. CASE NO.: DEPT: REPORT OF THE GUARDIAN OF THE ADULT PERSON through BEGINNING DATE ENDING DATEIf this is your first report, this is the date you were appointed the guardian. If this is a later report, this is the ending date of your last report. The date you sign this form. I, (guardian222s name) , am the Guardian of the above-named Protected Person. My annual report is as follows: General Information 1. The protected person222s birthdate is (date of birth) , and he / she is currently (age) years old. 2. How often have you visited the protected person in the last year? American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 10 226 Annual Report of Guardian (Adult) 3. Guardian222s Residency: ( check one) One or both guardians are Nevada residents. Neither guardian is a Nevada resident. ( check one) A registered agent is on file with the Nevada Secretary of State. No resident agent is on file with the Nevada Secretary of State. 4. Guardianship Alternatives: ( check one) I have talked with the protected person about alternatives to guardianship and how he/she could access such supports that may replace guardianship in the future. I have not talked with the protected person about alternatives to guardianship and how he/she could access such supports because: (explain why not) 5. Do you believe the protected person still needs a guardian? ( check one) Yes No (Explain why or why not) 6. The protected person222s current address and phone number is: Name of Facility (if applicable) Address City, State, Zip Code Telephone number 7. The address listed above is best described as: ( check one) Living independently in his/her private home, apartment, or condominium. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 10 226 Annual Report of Guardian (Adult) Living in in his/her private home, apartment, or condominium with another person or persons. List the names of all individuals living in this home (names of people living there): Living in someone else222s private home, apartment, or condominium. He/she lives with (names): An assisted living facility / supported adult residence / supported living arrangement. A skilled nursing home. A licensed group home. A medical facility, hospital, or psychiatric facility. A secured perimeter facility. Other (explain): . Is the facility locked? ( check one) Yes or No 8. Do you believe the protected person is happy with the living arrangement? ( check one) Yes No (Explain why or why not) 9. Appropriateness of Living Arrangement & Residential Supports. ( check all that apply) The current placement is appropriate as is. The current placement is appropriate with additional services (list the additional services needed) . Once the current medical situation is stable, the protected person will return to his/her previous residence. This is expected to happen on (estimated date of return): and he/she will return to live at (address) . American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 10 226 Annual Report of Guardian (Adult) A higher level of care is needed. The protected person should be placed at: ( check all that apply) An assisted living facility. A skilled nursing home. A licensed group home. A medical facility, hospital, or psychiatric facility. A secured perimeter facility. Other (explain): . The above option would be a more appropriate placement because (explain) Physical and Mental Health 10. The protected person has the following insurance coverage for medical / dental / mental health services: ( check all that apply) Medicare Medicare Part B Medicaid VA Health Benefits Prescription Drug Coverage (name of policy): Private Health Insurance (name of policy): Other (explain): 11. The protected person222s physical health is: ( check one) Good Fair Poor Describe the protected person222s overall physical health and physical limitations: American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 10 226 Annual Report of Guardian (Adult) 12. The protected person222s mental health is: ( check one) Good Fair Poor Describe the protected person222s overall mental health: 13. Medical Services. The protected person receives the following services: ( check all that apply) Regular dental visits (complete table below) Dentist Frequency Last Appt. Next Appt. Due Regular doctor visits (complete table below) Physician Reason Frequency Last Appt. Next Appt. Due *File any medical records showing any significant health problems with a Confidential Medical / Educational Information Sheet. Home health care every (how often, i.e. 223daily224 223weekly224 223monthly224) Full-time nursing care Hospice care American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 10 226 Annual Report of Guardian (Adult) 14. Mental Health Services. The protected person receives the following services: ( check all that apply) Behavioral health visits every (complete table below) Specialist Reason Frequency Last Appt. Next Appt. Due Psychiatric appointments every (complete table below) Psychiatrist Frequency Last Appt. Next Appt. Due 15. List all prescription medication in the table below. Medication Diagnosis/Reason Physician Last Reviewed by Doctor/Psychiatrist American LegalNet, Inc. www.FormsWorkFlow.com Page 7 of 10 226 Annual Report of Guardian (Adult) 16. Care Needs. The protected person222s personal care needs are: ( check all that apply) No assistance is needed in performing activities of daily living. Personal caregivers are needed. Caregivers are needed an average of (number) hours per week. Caregivers provide assistance with the following activities of daily living (explain what assistance is provided, such as housekeeping, bathing, meal preparation, etc.) Assistance with medication is required. 24-hour assistance is needed. 17. Medical / Mental Health Needs. The protected person requires the following medical or mental health examinations to determine necessary and/or ongoing treatment needs (describe any medical tests/appointments that are needed): 18. Abuse / Neglect. Has the protected person been abused or neglected in the last year? No Yes Describe the abuse / neglect and any steps taken to address the abuse / neglect: What agencies were notified of the abuse / neglect? Law Enforcement Elder Protective Services Ombudsman None What was the outcome of the investigation? American LegalNet, Inc. www.FormsWorkFlow.com Page 8 of 10 226 Annual Report of Guardian (Adult) Education 19. ( check one) The protected person is not enrolled in school. The protected person is enrolled in school. The protected person attends (name of school) . *File any report cards with a Confidential Medical/Informational Sheet. 20. The protected person had the following accomplishments and/or problems in school last year: (Describe or write 223N/A224) Activities & Recreation 21. The protected person222s recreation and social condition is: ( check one) Good Fair Poor 22. The protected person222s recreation and social activities include: ( check all that apply) Personal Community Activities (i.e. church, library, etc.): Group outings. (Describe) Family gatherings. (Describe) Senior community center events. (Describe) American LegalNet, Inc. www.FormsWorkFlow.com Page 9 of 10 226 Annual Report of Guardian (Adult) Work and/or training program. (Describe) Events at assisted living facility or nursing home. (Describe) None. (Describe why the protected person is not participating in any activities) Financial Information 23. ( check one) The protected person222s estate is less than $10,000. The protected person222s estate is more than $10,000. The finances are managed by (name of person handling the estate) . *An annual accounting must be filed detailing the estate assets, income, and expenses. Protected Person222s Wishes 24. Con