(Clerk’s Date Stamp) (Copy Receipt) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO. ___________________________ __________________________________ An Incapacitated Person PERIODIC PERSONAL CARE PLAN RCW 11.92.043 (PCP) 1. The Full Limited Guardian of the Person respectfully submits the following Personal Care Plan: 2. Custody and Residence of Incapacitated Person. The Incapacitated Person is now _______ years of age. He/She presently resides at _________________________________________________________________________ (name and address of facility or home). The Guardian believes that he/she is receiving satisfactory care and should continue to reside there. 3. Description of Services or Programs Incapacitated Person Receives. The Incapacitated Person receives the following services or programs: __________________________________ ____________________________________________________________________________ ____________________________________________________________________________ #22A-PERIODIC PERSONAL CARE PLAN PAGE 1 OF 3 Revised 5/07 American LegalNet, Inc. www.FormsWorkflow.com 4. Physical and Medical Status and Need of Incapacitated Person. The physical and medical status and needs of the Incapacitated Person are as follows: ______________________ _____________________________________________________________________________ _____________________________________________________________________________ 5. Mental and Emotional Status of Incapacitated Person. The mental and emotional status of the Incapacitated Person are as follows: ___________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 6. 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. ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. 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 identified and emerging personal care needs of the Incapacitated Person is as follows: ______________________________________________________________________________ ______________________________________________________________________________ 8. Contact Information for Facility or Home of Incapacitated Person, Guardian and Standby Guardian: Facility/Home Contact Guardian Standby Guardian Full Name Mailing Address City, State & Zip *Telephone Number #22A-PERIODIC PERSONAL CARE PLAN PAGE 2 OF 3 Revised 5/07 American LegalNet, Inc. www.FormsWorkflow.com I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. 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 *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 #S2Sealed Confidential Information and file in the confidential file. DO NOT ATTACH RECORDS PRODUCED AND SIGNED BY A HEALTH CARE PROVIDER TO THIS FORM. #22A-PERIODIC PERSONAL CARE PLAN PAGE 3 OF 3 Revised 5/07 American LegalNet, Inc. www.FormsWorkflow.com