Superior Court of Washington County of Snohomish In the Guardianship of: Case No. __________________ Initial Personal Care Plan GR 2 09-11 I. ASSESSMENT _______________________________, Incapacitated Person Check all that apply to the Incapacitated Person in each category: 1.1 Housing Composition: [ ] Lives Alone [ ] Lives with Spouse [ ] Lives with Children [ ] Lives with Relative [ ] Lives with Non-Relative [ ] Other: ______________________ 1.3 Living Arrangement: [ ] Home Owner [ ] Renter [ ] Adult Family Home [ ] Cong. Care Facility [ ] Nursing Home [ ] Senior Housing [ ] Other: ___________________________ 1.2 Primary Means of Transportation: [ ] Own Car [ ] Public Transportation [ ] Friend/Relative [ ] Other:_______________________ 1.4 If Lives in Home ­ Services Needed: [ ] None [ ] Chore Services (household chores) [ ] Other: _____________________________ ___________________________________ ___________________________________ S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR2.doc Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 1.5 Functional Limitation: [ ] Walker/Cane [ ] Speech [ ] Hearing [ ] Vision [ ] Walking 1.7 Needs Assistance For: [ ] Eating [ ] Toileting [ ] Ambulation [ ] Transfer [ ] Positioning [ ] Personal Hygiene [ ] Dressing [ ] Bathing [ ] Self Medication 1.8 Needs Assistance to Leave Home: [ ] Yes [ ] No 1.6 Prosthetic Devices: [ ] None [ ] Wheelchair [ ] Hearing Aid [ ] Artificial Limb [ ] Dentures [ ] Essential shopping with Incapacitated Person [ ] Essential shopping for Incapacitated Person [ ] Meal Preparation [ ] Laundry [ ] Facilities in Home [ ] Facilities out of Home [ ] Housework [ ] Travel to Medical Services Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. Circle one of the following codes for each item listed below: Y=Yes; N=No; CD= Cannot Determine. Y N CD 1.9 Incapacitated Person's Ability To Handle Emergencies: Knows what to do in the event of a fire. Knows what to do in case of medical emergency (doctor, ambulance). Knows what to do in the event of a break-in or robbery. Knows how to call emergency telephone services (911). 1.10 Incapacitated Person Knows How To Seek Help From Others To Keep Supply Of Goods and Obtain Services (Housekeeper, Lawyer, Community Services): Y Y Y Y N N N N CD CD CD CD Y N CD S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR2.doc Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 1.11 Incapacitated Person's Financial Abilities: Able to collect benefit, retirement, social security, V.A. benefits. Able to maintain checking accounts with balance greater than $_______. Able to pay monthly bills for rent, utilities, etc. Willing and able to spend money for necessary goods and services, i.e. food, clothing, sundries, etc. Able to seek help in money management. Able to manage funds. Y Y Y Y Y Y N N N N N N CD CD CD CD CD CD If someone other than the guardian of the person is guardian of the estate, or if the Incapacitated Person's assets are under the control of a trustee, provide the following information: List sources of income and/or resources to pay for monthly costs and care of the Incapacitated Person: _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. Estimated monthly costs and care of the Incapacitated Person: Housing: $ ____________ Other: Food: $ ____________ ________________ Utilities: $ ____________ ________________ Clothing and Laundry: $ ____________ ________________ Medical: $ ____________ ________________ Recreational: $ ____________ ________________ Insurance: $ ____________ ________________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ 1.12 Incapacitated Person's Psychological/Social/Cognitive Functioning: Y=Yes; N=No; CD= Cannot Determine. Y N CD A. Disorientation: Able to relate to person, place or time: B. Memory Impairment: Can remember events occurring within the hour: Can remember events occurring within the day: Can remember events occurring within the week: C. Impaired Judgment: Able to make appropriate decisions, solve problems, and respond to major life changes: D. Communications: Able to understand what is being said: Able to express thoughts and needs: Page 3 of 6 Y N CD Y Y Y N N N CD CD CD Y N CD Y Y N N CD CD S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR2.doc American LegalNet, Inc. www.FormsWorkFlow.com E. Wandering: Moves about aimlessly, or in pursuit of an unobtainable goal: F. Verbally Abusive Behavior: Threatens/berates others, yells, uses foul language, etc.: G. Disruptive or Inappropriate Behavior: Makes excessive demands for attention, takes another's possessions, disrobes in front of others, inappropriate sexual behavior, etc.: H. Assaultive or Combative Behavior: Throws objects, strikes or punches, makes dangerous maneuvers with wheelchair, etc.: I. Danger to Self: Indicated by self-neglect or harm, suicidal thoughts or attempts, etc.: J. Other Impairments in Thought, Moods, Behavior: Please Describe: ___________________________________________________________________. Y N CD Y N CD Y N CD Y N CD Y N CD II. Care Plan 2.1 Incapacitated Person's Residence _______________________________________________________________________________ Facility Name (if applicable) ________________________________________________________________________________ Address ________________________________________________________________________________ *Phone: 2.2 Plan for Chore Services Provided in Home (if necessary) _________________________________________________________________________________ _________________________________________________________________________________ ________________________________________________________________________________. 2.3 Plan for nursing services and other medical or personal care services provided in home,