(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO. _____________________ ____________________________________ An Incapacitated Person INITIAL PERSONAL CARE PLAN (PCP) I. ASSESSMENT Check all that apply in each category: 1. HOUSING COMPOSITION: Lives Alone Lives with Spouse Lives with Children Lives with Relative Lives with Non-Relative Other: _________________________ 3. LIVING ARRANGEMENT: Home Owner Renter Adult Family Home Cong. Care Facility Nursing Home Senior Housing Other: _________________________ 5. FUNCTIONAL LIMITATION: Speech Hearing Vision Walking #22-INITIAL PERSONAL CARE PLAN 2. PRIMARY MEANS OF TRANSPORTATION: Own Car Public Transportation Friend / Relative Other: __________________________________________ 4. IF LIVES IN HOME – SERVICES NEEDED: None Chore Services (household chores) Other : _________________________________________ ________________________________________________ ________________________________________________ 6. PROSTHETIC DEVICES None Walker/Cane Wheelchair Hearing Aid Artificial Limb Dentures PAGE 1 OF 5 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com 7. NEEDS ASSISTANCE FOR: Eating Toileting Ambulation Transfer Positioning Personal Hygiene Dressing Bathing Self Medication Travel to Medical Services Essential Shopping with IP Essential Shopping for IP Meal Preparation Laundry Facilities in Home Facilities out of Home Housework 8. NEEDS ASSISTANCE TO LEAVE HOME: Yes No Comments: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Circle one of the following codes for each item listed below: Y=Yes; N=No; CD=Cannot Determine. 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). 10. INCAPACITATED PERSON KNOWS HOW TO SEEK HELP FROM OTHERS TO KEEP SUPPLY OF GOODS AND OBTAIN SERVICES (HOUSEKEEPER, LAWYER, COMMUNITY SERVICES). 11. INCAPACITATED PERSON’S FINANCIAL ABILITIES: Able to collect benefit, retirement, social security, V.A. benefits. Able to maintain checking accounts with balance greater that $_______________ 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 N CD Y Y Y Y N N N N CD CD CD CD Y N CD Y Y Y Y N N N N CD CD CD CD Y Y N N CD CD List sources of income and/or resources to pay for monthly costs and care: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Estimated monthly costs and care: Housing: $________________ Food: $________________ Utilities: $________________ Clothing and Laundry: $________________ Medical: $________________ Recreational: $________________ Insurance: $________________ Other: ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 12. INCAPACITATED PERSON’S PSYCHOLOGICAL / SOCIAL / COGNITIVE FUNCTIONING: Y=Yes; N=No; CD=Cannot Determine. DISORIENTATION: #22-INITIAL PERSONAL CARE PLAN $________________ $________________ $________________ $________________ $________________ $________________ Y N CD PAGE 2 OF 5 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com Able to relate to person, place or time: Y N CD MEMORY IMPAIRMENT: Can remember events occurring within the hour: Y N CD Can remember events occurring within the day: Y N CD Can remember events occurring within the week: Y N CD IMPAIRED JUDGMENT: Able to make appropriate decisions, solve problems, and respond to major life Y N CD changes: COMMUNICATIONS: Able to understand what is being said: Y N CD Able to express thoughts and needs: Y N CD WANDERING: Moves about aimlessly, or in pursuit of an unobtainable goal: Y N CD VERBALLY ABUSIVE BEHAVIOR: Threatens / berates others, yells, uses foul language, etc.: Y N CD DISRUPTIVE OR INAPPROPRIATE BEHAVIOR: Makes excessive demands for attention, takes another’s possessions, disrobes in Y N CD front of others, inappropriate sexual behavior, etc.: ASSAULTIVE OR COMBATIVE BEHAVIOR: Throws objects, stikes or punches, makes dangerous maneuvers with Y N CD Wheelchair, etc.: DANGER TO SELF: Indicated by self-neglect or harm, suicidal thoughts or attempts, etc.: Y N CD OTHER IMPAIRMENTS IN THOUGHT, MOODS, BEHAVIOR: Please Describe: _____________________________________________________________________ II. 13. CARE PLAN IP’S RESIDENCE (facility name if applicable): Address: _____________________________________________________________________________ *Phone: _____________________________________________________________________________ Plan for chore services provided in home (if necessary): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Plan for nursing services and other medical or personal care services provided in home, adult family home, or congregate care facility (if necessary): _____________________________________________________________________________________ Plan for other services, including, rehabilitative, educational, social, and recreational services: _____________________________________________________________________________________ _____________________________________________________________________________________ #22-INITIAL PERSONAL CARE PLAN PAGE 3 OF 5 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com 14. 15. TREATING PHYSICIAN: NAME __________________________ __________________________ __________________________ ADDRESS ______________________________ ______________________________ ______________________________ PHONE/FAX NUMBER __________________________ __________________________ __________________________ CURRENT MEDICATIONS: _____________________________________________________________________________________ _____________________________________________________________________________________ 16. OTHER PROFESSIONALS ASSISTING INCAPACITATED PERSON: NAME ADDRESS PHONE/FAX NUMBER _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ 17. OTHER SIGNIFICANT PERSONS: NAME ADDRESS _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ 18. PHONE/FAX NUMBER _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ PLAN FOR FINANCIAL MANAGEMENT: (i.e. person(s) responsible to receive income and pay monthly bills.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SIGNED at ____________________, Washington this ______ day of _________________, 20______. ____________________________________ Signature of Guardian _______________________________________ Printed Name of Guardian, WSBA/CPG# ____________________________________ Address _______________________________________ City, State, Zip Code ____________________________________ *Telephone/Fax Number _______________________________________ Email Address #22-INITIAL PERSONAL CARE PLAN PAGE 4 OF 5 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com *Under GR 22 (b) (6), parties’ personal telephone number(s) are confidential information. If you do not want your personal phone number(s) on this public form, complete form #S2-Sealed Confidential Information and file in the confidential file. DO NOT ATTACH RECORDS PRODUCED AND SIGNED BY A HEALTH CARE PROVIDER TO THIS FORM. #22-INITIAL PERSONAL CARE PLAN PAGE 5 OF 5 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com