San Diego — Referral Information and List of Relatives

San Diego — Referral Information and List of Relatives PR-020 (Rev: 04/23)¶

Source: https://www.sdcourt.ca.gov/sites/default/files/sdcourt/generalinformation/forms/probateforms/pr020.pdf

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For your protection and privacy, press the Clear This Packet button on the last page after printing. CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional):

EMAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101

CONSERVATORSHIP OF

REFERRAL INFORMATION AND LIST OF RELATIVES CASE NUMBER
(CONFIDENTIAL)

The information provided in this form will assist the Court Investigator in completing a timely investigation. Complete ALL sections and provide as much detail as possible. This form must be filed with the Petition for Appointment of Probate Conservator (JC Form #GC-310) and each accounting or subsequent petition following the establishment of a conservatorship.

A. (Proposed) Conservatee:

Name: __________________________________________________________________ D.O.B.: ______________________
Address: ________________________________________________________________ Gate/Door Code: ____________ 3.Telephone No.: ___________________________________
Primary language spoken: English Spanish other: ____________________________________________________
Medi-Cal recipient? Yes No
Contact person (name/telephone): _________________ _______________________________________________________
Barriers to investigation/meeting (i.e. communication issues, safety hazards, aggressive behavior, etc.): _________________

Diagnosis: ___________________________________________________________________________________________

Medications currently being taken:

Major Neurocognitive Disorder

Name: (F.K.A. Dementia) Medication a. b. c. d. e. Additional medications listed on attachment A.
Name and address of secured facility where (proposed) conservatee will be/is placed, if requesting/granted authority under Prob. Code § 2356.5(b): __________________________________________________________________________________
Is there an LPS conservatorship? Yes No (If yes, list case number, name & address of LPS conservator)

B. (Proposed) Conservatee’s School/Facility/Day Program:

Name: ______________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Telephone No.: _____________________________________ Email: _________________________________________
Contact person (name/telephone): ________________________________________________________________________

SDSC PR-020 (Rev. 4/23) REFERRAL INFORMATION AND LIST OF RELATIVES Prob. Code, § 1826 (CONFIDENTIAL) Page 1 of 2

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CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER

C. Regional Center Information:

Location:__________________________________________________________________________________________
Contact person: __________________________ Telephone No. __________________ Email: ______________________

D. (Proposed) Conservator:

Name & Relationship (to proposed conservatee): _____________________________________________________________
Address: ____________________________________________________________________________________________
Telephone No.: ________________________________ _______
Email: ______________________________________________________________________________________________
Primary language spoken: English Spanish other: _____________________________________________________ E. (Proposed) Co-Conservator:
Name & Relationship (to proposed conservatee): ____________________________________________________________
Address: ____________________________________________________________________________________________
Telephone No.: ________________________________
Email: ______________________________________________________________________________________________
Primary language spoken: English Spanish other: ____________________________________________________ Additional (proposed) co-conservators listed on attachment D.

F. (Proposed) Conservatee’s Relatives: List conservatee’s spouse or registered domestic partner, 1st degree relatives (parents and children), and 2nd degree relatives (brothers and sisters, grandparents and grandchildren), so far as known to petitioner(s). If there are no known relatives, list conservatee’s neighbors and close friends, if known. Name: Relationship: Tel. No(s).: Email: Minor Main: 1. Work: Main: 2. Work: Main: 3. Work: Main: 4. Work: Main: 5. Work: Main: 6. Work: Main: 7. Work: Main: 8. Work: Additional relatives listed on attachment F.

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: _____

Type or Print Name Signature of Petitioner

SDSC PR-020 (Rev. 04/23) REFERRAL INFORMATION AND LIST OF RELATIVES Prob. Code, § 1826 (CONFIDENTIAL) Page 2 of 2 Clear This Form

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