Alameda — Status Report on Conservatee Form

Source: https://www.alameda.courts.ca.gov/system/files/forms-and-filings/status-report-conservatee-form.pdf

COURT INVESTIGATOR'S OFFICE BERKELEY COURTHOUSE 2120 MARTIN LUTHER KING, JR. WAY BERKELEY, CA 94704

SUPERIOR COURT - ALAMEDA COUNTY

STATUS REPORT ON CONSERVATEE
(Local Court Rule 7.870)

In the Matter of the Conservatorship of: ) PROBATE NUMBER:
)
) HEARING DATE:
,Conservatee )

THIS IS A CONFIDENTIAL REPORT

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CONFIDENTIAL STATUS REPORT

Name of Conservatee: _____________________________________________ Probate No.: ___________________

Current Residence: _____________________________________________________________________________

_____________________________________Phone:

Please provide the following information about the conservatee.

1. Current Health Status - a) Doctor's Name: _________________________________Date of last appointment: ___________________ b) Describe conservatee’s current health status, including diagnoses. _____________________________

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   c) Describe any significant health changes since the last review. __________________________________

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2. Current Function Level - a) Describe conservatee's ability to care for self _________________________________________________

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   b) Describe conservatee’s communication/understanding level ___________________________________

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   c) Describe any significant changes in the conservatee’s ability to care for self or

   communicate/understand since the last review.

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3. Current General Well Being - a) Describe the current living situation (own home/board & care/skilled nursing/etc.)

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   b) If the conservatee lives at home, does he/she receive IHSS benefits? ___________________________ If, yes, name of care provider__________________________________________Phone________________

   Name of social worker at IHSS __________________________Phone c) Describe any plans to change the living situation _____________________________________________ ________________________________________________________________________________________ d) Date of last visit by conservator ____________________________________________________________ Frequency of visits by conservator ___________________________________________________________ Does the conservatee have other visitors? ____________________________________________________

4. Current estate situation - a) Present market value ____________________________________________________________________ b) Adequate to meet needs of the conservatee ________________________________________________ Explain_________________________________________________________________________________ c) If you plan to make significant changes in the way the estate is being handled, please describe

   them. (e.g., a reverse annuity mortgage in order to keep the conservatee in own home).

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5. Name and phone no. of Day Program, if applicable____________________________________________

6. Conservator’s comments - Please indicate any unusual problems/successes you wish the court to be

   aware of that occurred since the last review. __________________________________________

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   I declare under penalty of perjury that the foregoing is true and correct.

   Date signed: ______________________________ __________________________________________SIGN Conservator’s Signature

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   Mailing Address City, State, Zip Code

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   Telephone Number/Email address *Attach additional pages if necessary.

   CONFIDENTIAL STATUS REPORT

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