San Mateo — Form GC313: Attachment Requesting Special Orders Regarding Dementia (Petition for Appointment of Probate Conservator or Exclusive Authority to Give Consent for Medical Treatment)

Source: https://courts.ca.gov/sites/default/files/courts/default/2024-11/gc313.pdf

GC-313 CONSERVATORSHIP OF (Name): CASE NUMBER: CONSERVATEE ATTACHMENT REQUESTING SPECIAL ORDERS REGARDING A MAJOR NEUROCOGNITIVE DISORDER Petition for Appointment of Probate Conservator (form GC-310) Petition for Exclusive Authority to Give Consent for Medical Treatment (form GC-380)

1. Petitioner requests that the conservator of the person be authorized a. to place the conservatee in a secured-perimeter residential care facility for the elderly operated under Health and Safety Code section 1569.698 that has a care plan that meets the requirements of California Code of Regulations, title 22, section 87705. b. to authorize the administration of medications appropriate for the care and treatment of major neurocognitive disorders (including dementia).

2. The conservatee or proposed conservatee has a major neurocognitive disorder (such as dementia) as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

3. A medical declaration executed by a licensed physician or a licensed psychologist acting within the scope of his or her license with at least two years' experience in diagnosing and treating major neurocognitive disorders (including dementia): a. has been filed. b. will be filed before the hearing.

4. Restricted placement. The conservatee needs or would benefit from placement as requested in item 1a. The conservatee lacks capacity to give informed consent to this placement. The placement requested is the least restrictive placement appropriate to the needs of the conservatee.

5. Medications. The conservatee needs or would benefit from administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia). The conservatee lacks capacity to give informed consent to the administration of those medications.

Form Adopted for Mandatory Judicial Council of California Use ATTACHMENT REQUESTING SPECIAL ORDERS Probatewww.courts.ca.govCode, § 2356.5 GC-313 [Rev. January 1, 2019] REGARDING A MAJOR NEUROCOGNITIVE DISORDER

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