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Personal Care Plan Form. This is a Washington form and can be use in King Local County.
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Tags: Personal Care Plan, 11, Washington Local County, King
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IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON
IN AND FOR THE COUNTY OF KING
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In the Guardianship of:
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______________________________,
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An Incapacitated Person.
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) Case No.:
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) PERSONAL CARE PLAN
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) (PCP)
COMES NOW ______________________, the [
] Full [
] Limited Guardian of
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the Person, respectfully submits the following Personal Care Plan:
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1.
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_____ years of age. He/She presently resides at: ______________________________(name
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and address of facility or home). The Guardian believes that he/she is receiving satisfactory
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care, and should continue to reside there.
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2.
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Custody and Residence of Incapacitated Person. The Incapacitated Person is now
Description of Services or Programs Incapacitated Person Receives. The
Incapacitated Person receives the following services or programs: _____________________
__________________________________________________________________________
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Physical and Medical Status and Need of Incapacitated Person. The physical and
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medical status and needs of the Incapacitated Person are as follows:____________________
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__________________________________________________________________________
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_________________________________________________________________________.
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PERSONAL CARE PLAN - 1
12/2005 REVISED GUARDIANSHIP FORMS
American LegalNet, Inc.
www.USCourtForms.com
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status of the Incapacitated Person is as follows:
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________________________________________________________________________
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5.
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Mental and Emotional Status of Incapacitated Person. The mental and emotional
Description of Functional Abilities of the Incapacitated Person. The following is
a description of the Incapacitated Person’s abilities to perform and/or assist in the activities
of daily living. ___________________________________________________
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Guardian’s Specific Plan for Meeting the Identified and Emerging Personal
Care Needs of the Incapacitated Person. The Guardian’s specific plan for meeting the
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identified and emerging personal care needs of the Incapacitated Person is as follows:
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________________________________________________________________________
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I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE
STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
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SIGNED at _____________, Washington this _______ day of_________, 200___ .
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Signature of Guardian
Printed Name of Guardian, WSBA/CPG#
Address
Telephone/Fax Number
City, State, Zip Code
Email Address
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PERSONAL CARE PLAN - 2
12/2005 REVISED GUARDIANSHIP FORMS
American LegalNet, Inc.
www.USCourtForms.com
