San Luis Obispo — PR010

Source: https://www.slo.courts.ca.gov/documents/san-luis-obispo/PR_010_SLO.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY

TELEPHONE NUMBER: FAX NO. (Optional):

EMAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO

STREET ADDRESS: 1035 Palm Street, Room 385
MAILING ADDRESS: Same as above
CITY AND ZIP CODE: San Luis Obispo, CA 93408
BRANCH NAME: San Luis Obispo Division

LPS CONSERVATORSHIP OF: CASE NUMBER:

CONFIDENTIAL MEDICAL INFORMATION IN SUPPORT OF
REAPPOINTMENT OF LPS CONSERVATOR

DECLARATION OF PHYSICIANS OR QUALIFIED LICENSED
PSYCHOLOGISTS FOR REAPPOINTMENT OF LPS CONSERVATORSHIP

Form Adopted for Optional Use CONFIDENTIAL MEDICAL INFORMATION Page 1 of 3San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15

LPS CONSERVATORSHIP OF: CASE NUMBER

DECLARATION OF PHYSICIAN OR QUALIFIED LICENSED PSYCHOLOGIST FOR REAPPOINTMENT OF LPS CONSERVATORSHIP (Welfare & Institutions Code §5361)

□ The renewal of the conservatorship of __________________________________for an additional one year period IS NOT recommended because this person is no longer gravely disabled as defined under §5008(h)(1)(a) of the Welfare & Institutions Code.

□ The renewal of the conservatorship of ___________________________________for an additional one year period IS recommended because this person is still gravely disabled as defined under §5008(h)(1)(a) of the Welfare & Institutions Code.

Date of current evaluation: ____________________________.

1. Is there a current mental disorder? ____________________________________.
2. Current Diagnosis:_________________________________________________.
3. Current Mediations:_________________________________________________

__________________________. 4. Please explain the symptoms.

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__________________________________________________________________. 5. Can the individual provide for his or her basic needs (i.e., food, clothing, or shelter) in an unsupervised setting? Why do you feel he or she can or cannot? ____

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__________________________________________________________________.

6. Conservatee’s Current Placement Level of Care __________________________.

The least restrictive level of care in which this person can be treated is: □ Locked IMD □ Skilled Nursing Facility □ Licensed Board and Care □ Other _____________________.

□ This person lacks capacity to give informed consent, or is unable or unwilling to voluntarily consent to treatment specifically related to his/her being gravely disabled as follows: (Note, if this box is checked, please also check box #1 under Imposition of Disabilities below). _________________________________________________ __________________________________________________________________. □ This person lacks capacity to give informed consent for routine medical treatment unrelated to remedying or preventing the recurrence of his/her being disabled as follows: (Note, if this box is checked, please also check box #2 under Imposition of Disabilities below). ___________________________________________________ __________________________________________________________________.

Form Adopted for Optional Use CONFIDENTIAL MEDICAL INFORMATION Page 2 of 3San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15

LPS CONSERVATORSHIP OF: CASE NUMBER

Imposition of Disabilities: I make the following recommendations regarding the
imposition of disabilities on the above named person:

□ 1. Conservatee should not have the right to consent to treatment related
specifically the Conservatee’s being gravely disabled.
□ 2. Conservatee should not have the right to consent to routine medical treatment
unrelated to remedying or preventing the recurrence of the Conservatee’s grave
disability.
□ 3. Conservatee should not possess a license to operate a motor vehicle.
□ 4. Conservatee should not be allowed to enter into contracts in excess of $15.00.
□ 5. Conservatee should not have the right to possess, have custody of, or control a
firearm or any other deadly weapon because it would present a danger to the safety
of the person or to others.
□ 6. Conservatee should not have the right to vote because the Conservatee is not
capable of completing an affidavit of voter registration.

I declare that I am a □ physician, licensed in the State of California, OR □ a
psychologist licensed in the State of California, who has a doctoral degree in
psychology and at least five years of postgraduate experience in the diagnosis and
treatment of emotional mental disorders.

I declare under penalty of perjury under the laws of the State of California that the
foregoing is true and correct. Executed on (date): _________________

_______________________________ __________________________
Printed Name Signature (blue ink)

I declare that I am a □ physician, licensed in the State of California, OR □ a
psychologist licensed in the State of California, who has a doctoral degree in
psychology and at least five years of postgraduate experience in the diagnosis and
treatment of emotional mental disorders.

I declare under penalty of perjury under the laws of the State of California that the
foregoing is true and correct. Executed on (date): _________________

_______________________________ __________________________
Printed Name Signature (blue ink)

Form Adopted for Optional Use CONFIDENTIAL MEDICAL INFORMATION Page 3 of 3San Luis Obispo Superior Court Local Form PR010 Rev. 1/1/15