GC-335A Everyday Activities Attachment to Confidential Capacity Assessment and Declaration—Probate Conservatorship

Source: https://www.courts.ca.gov/documents/gc335a.pdf

CONFIDENTIAL GC-335A CONSERVATORSHIP OF THE PERSON ESTATE OF CASE NUMBER: (name): CONSERVATEE PROPOSED CONSERVATEE

EVERYDAY ACTIVITIES ATTACHMENT TO CONFIDENTIAL CAPACITY ASSESSMENT AND DECLARATION—PROBATE CONSERVATORSHIP (FORM GC-335)

This form is for optional use in a probate conservatorship proceeding, in conjunction with Confidential Clinical Assessment and Declaration—Probate Conservatorship (form GC-335), to indicate the ability of the person described in item 1 to perform activities of daily living and instrumental activities of daily living. The person whose abilities are described on this form

1. a. Name: b. Address: Telephone number: Email address: Date of birth:

The person who is completing this form 2. a. Name: b. Office address: Telephone number: Email address: 3. a. I am a California-licensed physician psychologist nurse practitioner physician assistant registered nurse clinical social worker occupational therapist other licensed professional (specify profession): b. My license number is: 4. Check the box or boxes that apply to you. a. I am the clinician who conducted the assessment of the person named in item 1 documented on the Confidential Clinical Assessment and Declaration—Probate Conservatorship (form GC-335) to which this form is attached, and I completed that form. The conclusions and opinions given in this form are based on the same assessment. b. I work or consult with the clinician who completed the Confidential Clinical Assessment and Declaration—Probate Conservatorship (form GC-335) to which this form is attached, and I participated in that clinician's assessment of the person named in item 1. The conclusions and opinions in this form are based on my participation in that assessment. c. The conclusions and opinions given in this form are based on the application of my knowledge, experience, and training to my personal observations of the person named in item 1, as described below.

Items 5–11 describe my conclusions about the ability of the person named in item 1 to perform activities in each of the listed categories based on information gathered as described in item 4.

Activities of Daily Living (care of self and related activities) 5. Maintain adequate hygiene (for example, bathing, grooming, dressing, caring for teeth, going to the toilet) Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 5.

Form Approved for Judicial Council of California Optional Use EVERYDAY ACTIVITIES ATTACHMENT TO CONFIDENTIAL CAPACITY Probate1872–1873,Code,2351,§§ 1800.3,2351.5, 1801,2450 www.courts.ca.govGC-335A [New January 1, 2025] ASSESSMENT AND DECLARATION—PROBATE CONSERVATORSHIP

CONFIDENTIAL GC-335A CONSERVATORSHIP OF THE PERSON ESTATE OF CASE NUMBER: (name): CONSERVATEE PROPOSED CONSERVATEE Activities of Daily Living (care of self and related activities) 6. Prepare meals and eat for adequate nutrition Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 6.

7. Identify abuse or neglect and protect self from harm Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance

Comments below in Attachment 7.

Instrumental Activities of Daily Living 8. Financial (if appropriate, note dollar limits) a. Protect and spend small amounts of cash Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 8a.

b. Manage and use checks; pay monthly bills
Able; fully Able with advice Able only with Unable, even I don't know
independent and passive support active assistance with assistance
Comments below in Attachment 8b.

c. Enter into a contract (including, for example, to buy, sell, or lease real property or to obtain and use a credit card)
Able; fully Able with advice Able only with Unable, even I don't know
independent and passive support active assistance with assistance
Comments below in Attachment 8c.

9. Resist fraud or undue influence (for example, has a history of being a victim of fraud or undue influence) Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance

Comments below in Attachment 9.

10. Medical a. Choose and direct caregivers Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 10a.

GC-335A [New January 1, 2025] EVERYDAY ACTIVITIES ATTACHMENT TO CONFIDENTIAL CAPACITY Page 2 of 4 ASSESSMENT AND DECLARATION—PROBATE CONSERVATORSHIP

CONFIDENTIAL GC-335A CONSERVATORSHIP OF THE PERSON ESTATE OF CASE NUMBER: (name): CONSERVATEE PROPOSED CONSERVATEE

10. b. Admit self to health-care facility Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 10b.

    c. Manage own medication (take proper dose as scheduled; refill or renew prescriptions as needed) Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 10c.

    d. Contact help if ill or in an emergency Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 10d.

11. Home and community life a. Maintain a reasonably safe and clean home or other living environment; arrange for home maintenance or repair Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 11a.

    b. Recognize and avoid common hazards (for example, a hot stove or poisons) Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 11b.

    c. Access transportation (for example, drive a car or use public transportation) Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 11c.

    d. Initiate and follow a schedule of daily activities Able; fully Able with advice Able only with Unable, even I don't know independent and passive support active assistance with assistance Comments below in Attachment 11d.

GC-335A [New January 1, 2025] EVERYDAY ACTIVITIES ATTACHMENT TO CONFIDENTIAL CAPACITY Page 3 of 4 ASSESSMENT AND DECLARATION—PROBATE CONSERVATORSHIP

CONFIDENTIAL GC-335A CONSERVATORSHIP OF THE PERSON ESTATE OF CASE NUMBER: (name): CONSERVATEE PROPOSED CONSERVATEE

12. Other information regarding my assessment of the person's ability to perform activities of daily living or instrumental activities
    of daily living, including any significant impairments to that ability, is given below in Attachment 12.

13. Number of pages attached:

I declare 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 DECLARANT)

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