Madera — Conservatorship Investigation Intake/Questionnaire (MAD-FCS-006)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-fcs-006-conservatorship-investigation-intake-questionnaire-rev-04-15-2020_0.pdf

STATE OF CALIFORNIA MADERA SUPERIOR COURT CONSERVATORSHIP INVESTIGATION Family Court Services INTAKE/QUESTIONNAIRE 200 South G Street Madera, CA 93637 PH#: (559)416-5560 FAX#:(559)673-8216 INITIAL CONSERVATORSHIP CONSERVATORSHIP TERMINATION

COURT CASE#: _____________________ FCS#: ______________ NEXT COURT DATE: ___________________

NOTE: INVESTIGATION FEE OF $400 IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT SECTION 1: CONSERVATOR/PETITIONER’S INFORMATION NAME (Last, First, Middle) RELATIONSHIP TO CONSERVATEE: MAIDEN NAME: OTHER NAMES KNOWN BY:

DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS:

STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE:

CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS:__________ SECTION 2: CONSERVATEE INFORMATION NAME (Last, First, Middle) CURRENT MEDICAL DIAGNOSES:

DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

TEL. #: PHYSICIANS NAMES AND TELEPHONE NUMBERS:

STREET ADDRESS: SOCIAL SECURITY #: DOES THE CONSERVATEE HAVE A CAPACITY DECLARATION? Yes No

CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS:__________ SECTION 3: OBJECTING WITNESS INFORMATION NAME (Last, First, Middle) RELATIONSHIP TO CONSERVATEE: MAIDEN NAME: OTHER NAMES KNOWN BY:

DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS:

STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE:

CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS:__________

MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 1

SECTION 4: CONCERNS AND PROPOSALS 1. Reasons for or against the Conservatorship: a. Petitioners: What are the circumstances that lead to your decision to petition for Conservatorship or a change to the current Conservatorship? b. Objecting Witness: What are the top three reasons why the Conservatorship should not be granted? ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ c. Is there currently a temporary Conservatorship in place? Yes No d. What is the Conservatee’s usual routine, including times for wake-up, meals, bath, recreation, sleep, work, and attendance at any programs? ___________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ e. Please summarize your plans for the Conservatee. Include plans for the daily care, support, supervision and control of the Conservatee regarding health, education, religion, and recreation: ___________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ f. How often will you be able to visit the Conservatee if the Conservatee is placed in a care facility? ______________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ g. If home care is the option used, will other family members and friends be able to visit the Conservatee on a regular basis? Yes No What are the best days and hours for visitors? _________________________________ ___________________________________________________________________________________________

MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 2

SECTION 5: INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: Full name: Date of birth: Social Security #:

Other names used: Driver’s license #/State: Date relationship began:

Home phone number: Cell phone number: Occupation:

Present employer: Employer’s phone #: Days/Hours worked:

SECTION 6: EDUCATION AND EMPLOYMENT A. Education Level: Please list the highest grade or level of schooling you completed: GED High school graduate College courses taken College graduate Post graduate work 1. Are you currently employed? Yes No 2. IF YES, what is your occupation, employer’s name, telephone number and employer’s address? ____________________________________________________________________________________ ____________________________________________________________________________________

3. How long have you been with your current employer? Years: ____ Months: ____

4. Current workdays and hours (please list what time you start work and what time you end work each day):

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

5. Please list your employment history over the past 5 years:

Dates of employment: Name of employer: Telephone #: Occupation: Reason for leaving:

6. Who takes care of the Conservatee when you are unavailable? Please provide their names/telephone #’s:

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SECTION 7: MENTAL HEALTH HISTORY 1.Have you ever been in counseling or therapy? Yes No IF YES, please list in chronological order (by year) the therapists, counselors, clergy and/or marital counselors who you have gone to: Date: Doctor/Therapist name: Complete mailing address: Telephone #:

2.Have you ever been hospitalized for psychiatric treatment? Yes No (see next page if yes)

MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 3

IF YES, please list hospitals or clinics attend and the dates of treatment: Date: Hospital name: Complete mailing address: Telephone #:

3. Have you ever taken psychiatric medication? Yes No (for example, for depression, anxiety, etc.)
IF YES, please list the names of all medications and the name, telephone number and the complete mailing
address of the physician who prescribed the medication. _____________________________
____________________________________________________________________________________

4. Has the Proposed Conservatee ever been in counseling/therapy or hospitalized for psychiatric treatment? Yes No IF YES, please list the therapist, agency or hospital that provided the services and the dates of treatment.

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5. Please list the names of all of the Conservatee’s medications and the name, telephone number and the complete mailing address of the physician who prescribed the medication: _______________________________________ ___________________________________________________________________________________________

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SECTION 8: ALCOHOL AND SUBSTANCE ABUSE HISTORY 1. What kind(s) of alcohol do you drink?___________________________________________________ 2. How often do you drink? ____________________________________________________________ 3. Has your drinking ever been an issue between you and your family or friends? Yes No 4. Are you currently in or have you ever received treatment for alcohol abuse? Yes No If yes, please check all applicable treatment: Counseling/Therapy Detox Rehab Inpatient Rehab Outpatient AA/NA 5. If a box was checked, please list, in chronological order, the therapist/agency/hospital utilized: Date: Therapist/Hospital: Complete mailing address: Tel #:

6. Drug use history:

Name of drug: How often: Age of first use: Date of last use:

7. Prescription drug use history:

Name of drug / # milligrams: How often taken: Prescribing doctor: Doctor’s phone number:

8. Do you have a medical marijuana card? Yes No Expiration Date:_____________________________
9. Have drugs or alcohol ever caused you to lose a job? Yes No

MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 4

10. Has your drug use ever been an issue between you and your family and friends? Yes No 11. Have you ever been court ordered for drug testing? Yes No IF YES, When? ____________________ 12. Were the results of the drug tests positive? For what drugs? _______________________________________ ________________________________________________________________________________________

SECTION 9: YOUR RELATIONSHIP WITH THE CONSERVATEE 1. Please describe the Conservatee (check off those that apply):

a. Activity level: high energy low energy

b. Attention: able to focus easily distracted

c. Level of intensity when upset: reacts dramatically becomes quiet

d. Gets hungry or tired: at predictable times at unpredictable times

e. Response to stimulation: startles easily to sounds remains calm

f. Appetite: picky eater will eat anything

g. Adaptability: approaches new situations easily takes a long time to become comfortable

h. When faced with obstacles (for ex: putting together a puzzle): is patient

gives up easily

i. Mood in general: the Conservatee is positive and happy the Conservatee focuses on the negative

2. What does the Conservatee do well?_____________________________________________________________
___________________________________________________________________________________________
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3. What kinds of problems does the Conservatee have (Social, emotional, intellectual)?________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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4. What have you done to try to help the Conservatee with these problems? ________________________________
___________________________________________________________________________________________
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SECTION 10: YOUR FAMILY BACKGROUND AND OTHER INFORMATION 1. What are/were your parents’/stepparents’ names and occupations? __________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. What are your siblings’ names? What place are you in the birth order?___________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

3. Who lived with you growing up? What role did they play in your life? ___________________________________

MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 5

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4. What was the quality of your parents’ relationship with each other growing up? What is it like now?

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5. Did your parents divorce? If so, who did you live with? What effect did the divorce have on you?

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6. Were there any issues in the home growing up such as substance abuse or mental health issues?

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7. What is your current relationship with each of your siblings? (for example, Close? Strained? None? Needs improvement?)_______________________________________________________________________________

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8. What issues, if any, did you experience during your early adulthood in school, with peers, with substance abuse or mental health? ______________________________________________________________________________

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9. What was the parenting role of your mother and your father growing up? _________________________________

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SECTION 11: PLEASE LIST THE NAMES AND BIRTH DATES OF ALL OTHER ADULTS LIVING IN YOUR HOME:

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SECTION 12: WHAT ELSE WOULD YOU LIKE THE INVESTIGATOR TO KNOW?

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MAD-FCS-006 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 6