Fresno — Confidential Conservatorship Care Plan – Part 2

Source: https://www.fresno.courts.ca.gov/system/files/forms-and-filings/gc-356-confidential-conservatorship-care-plan-part-2.pdf

GC-356 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME:

FIRM NAME:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE NO.: FAX NO.:

EMAIL ADDRESS:

ATTORNEY FOR (name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CONSERVATORSHIP OF (name): CONSERVATEE CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 2 CASE NUMBER: (MEDICAL INFORMATION)

To the conservator of the person: Complete items 1–4; if you want to discuss additional medical information, complete item 5; and sign the form on page 2. Deliver this form as instructed on page 6 of form GC-355, then file this form, Confidential Conservatorship Care Plan—Part 1 (form GC-355), and proof of delivery with the court. A care plan is not complete without this form and form GC-355. To the clerk: File this form separately from Confidential Conservatorship Care Plan—Part 1 (form GC-355) to ensure that the confidential medical information contained in this form is not improperly disclosed.

1. The conservatee has been diagnosed with the following physical or mental health conditions (check all that apply): a. No known health conditions. b. Physical health conditions described below. on Attachment 1b.

   c. Mental health conditions described below. on Attachment 1c.

2. The conservatee is receiving or using the following medical treatment, medications, supports, or devices for one or more of the conditions described in item 1 (complete all that apply): a. No medical treatment, medications, supports, or devices. b. All medical treatments and the conditions treated by each are described below. on Attachment 2b.

   c. All medications taken and the conditions treated by each are described below. on Attachment 2c.

   d. All services and supports received, including the reason for each, are described below. on Attachment 2d.

   e. All devices used and the purpose of each are described below. on Attachment 2e.

Form Adopted for Mandatory Use Probate Code, § 2351.2 Judicial Council of California CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 2 www.courts.ca.gov GC-356 [New January 1, 2025] (MEDICAL INFORMATION)

GC-356 CONSERVATORSHIP OF CASE NUMBER: (name): CONSERVATEE

3. a. The medical treatment, medications, supports, and devices described in item 2 are sufficient to meet the conservatee's current and foreseeable medical needs. b. The additional medical treatment, medications, supports, or devices described below on Attachment 3b are necessary to meet the conservatee's current and foreseeable medical needs.

4. The following health care providers are currently providing treatment or care to the conservatee (give name, professional license type [e.g., physician, cardiologist or other specialist, dentist, psychotherapist] and license number, and contact information for each; if you know, describe the treatment and care provided): a. Name: Professional license type: License number: Mailing address:

   Telephone number: Email address: Treatment or care provided (if known):

   b. Name: Professional license type: License number: Mailing address:

   Telephone number: Email address: Treatment or care provided (if known):

   c. Name: Professional license type: License number: Mailing address:

   Telephone number: Email address: Treatment or care provided (if known):

   Additional providers listed on Attachment 4.

5. Additional confidential medical information is discussed below. on Attachment 5.

Date:

(TYPE OR PRINT NAME) (SIGNATURE)

GC-356 [New January 1, 2025] CONFIDENTIAL CONSERVATORSHIP CARE PLAN—PART 2 Page 2 of 2 (MEDICAL INFORMATION)