Fill and Sign the Ad Litem Guardianship Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Report of Guardian ad Litem (Guardianship Due to Incompetency)       Date of Birth Case No.       I am the court appointed Guardian ad Litem for the above named individual and report to the court that I have completed the following duties (except as noted in the “Additional Comments” section at the end of this report) and make the following report and recommendations: GENERAL DUTIES 1. INTERVIEWED INDIVIDUAL AND ADVISED INDIVIDUAL OF RIGHTS AND PROCEDURE. On ( date )       at ( place )       , I interviewed individual and explained to the individual the contents of the petition, the applicable hearing procedure, the right to counsel, and the right to request or continue a limited guardianship. I advised individual, both orally and in writing of that person’s right to be present at the hearing, to a jury trial, to an appeal, to counsel, and to an independent medical or psychological examination on the issue of competency, at county expense if the person is indigent. 2. INTERVIEWED PROPOSED GUARDIAN(S). I interviewed the proposed guardian, proposed stand-by guardian, if any, and any other person seeking appointment as guardian. 3. REVIEWED ADVANCE PLANNING. I have reviewed any power of attorney for health care under ch.155, any durable financial power of attorney under ch. 243 executed by the individual, any other advance planning for financial and health care decision making in which the individual had engaged. 4. INTERVIEWED AGENT. I have interviewed any agent appointed by the individual under any document specified above. 5. RECEIVED NOTICE OF HEARING AND COPIES OF REPORTS. I have received proper notice of the hearing and copies of the physician’s and/or psychologist’s reports. If protective placement is being requested, I have received a copy of the comprehensive evaluation and, if applicable, the plan for home or community-based care. 6. PROVIDED NOTIFICATIONS. I have notified the petitioner or petitioner’s counsel (if any) of the information contained below. I have also notified the appointed guardian (if any) of the duty to be present at and right to participate in the hearing, to present and cross-examine witnesses, to receive a copy of any comprehensive evaluation, and to secure and present a report on an independent evaluation. REPORT AND RECOMMENDATIONS 7. OBJECTIONS. The individual: does not does object to a finding of incompetency. does not does object to the proposed or present placement. does not does object to the recommendation of the guardian ad litem. is not is ambiguous on these matters. 8. ADVERSARY COUNSEL. Adversary counsel is not is requested by the individual. GN-3160, 10/06 Report of Guardian ad Litem (Guardianship Due to Incompetency) §§54.40, 54.42 and 55.10(4)(b), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 4 Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 2 of 4 Case No. Adversary counsel is not is recommended. 9. JURY TRIAL. A jury trial is not demanded. is demanded. 10. INDIVIDUAL’S ATTENDANCE. Regarding the individual’s attendance at the hearing: it is my opinion that the individual can attend the hearing in court. I waive the individual’s presence after considering the ability of the individual to understand and meaningfully participate, the effect of the individual’s attendance on his/her physical or psychological health in relation to the importance of the proceedings and the individual’s expressed desires. Specify reasons:       the individual is unable to attend the hearing in court because of residency in a nursing facility or other facility, physical inaccessibility, or a lack of transportation; and the individual, advocate counsel, other interested person, or I request that the court hold the hearing in a place where the individual can attend. Specify location requested:       11. ADDITIONAL EVALUATIONS. Additional medical, psychological or other evaluation is not is requested. Specify evaluation requested and reason:       . 12. ADVANCED PLANNING. My report to the court is that the individual’s advance planning is is not adequate to preclude the need for guardianship.       13. BEST INTERESTS OF INDIVIDUAL. Based on my investigation, I recommend that the court find that the individual is substantially: capable of caring for himself/herself. incapable of caring for himself/herself. capable of managing his/her property. incapable of managing his/her property. 14 . RIGHTS AND POWERS. That the individual has incapacity in part or in full to exercise rights that are believed to be relevant to the individual’s present or future decision making as follows: A. Rights to be removed from the individual. consent to marriage. execute a will. serve on a jury. apply for an operator’s license, a hunting, fishing or other license issued under ch. 29, or a credential as defined in §440.01(2), Wisconsin Statutes:       consent to sterilization. consent to organ, tissue, or bone marrow donation. register to vote or vote in an election. B. Rights the individual may exercise only with the consent of the guardian of the person. consent to marriage. apply for an operator’s license, a hunting, fishing or other license issued under ch. 29, or a credential as defined in §440.01(2), Wisconsin Statutes:       consent to sterilization. consent to organ, tissue, or bone marrow donation. GN-3160 10/06 Report of Guardian ad Litem (Guardianship Due to Incompetency) §§54.40, 54.42 and 55.10(4)(b), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 4 Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 3 of 4 Case No. C. Powers the individual has incapacity to exercise and extent of assignment to the guardian of person. consent to medical examination and treatment, and consent to voluntary medication, including psychotropic medication that is in the individual’s best interests, if the guardian has first made a good- faith attempt to discuss with the individual the individual’s voluntary receipt of the psychotropic medication and the individual does not protest. Guardian of person’s authority: full limited       authorize individual’s participation in an accredited or certified research project if the research project might help the individual, or others if minimal risk of harm. Guardian of person’s authority: full limited       authorize individual’s participation in research that might not help the individual but might help others if greater than minimal risk of harm to the individual but evidence indicates individual would have elected to participate. Guardian of person’s authority: full limited       consent to experimental treatment in the individual’s best interests. Guardian of person’s authority: full limited       consent to receipt by individual of social and supported living services. Guardian of person’s authority: full limited       consent to release of confidential records other than court, treatment, and patient health care records and redisclosure as appropriate. Guardian of person’s authority: full limited       power to make decisions related to mobility and travel. Guardian of person’s authority: full limited       power to choose providers of medical, social, and supported living services. Guardian of person’s authority: full limited       power to make decisions regarding educational and vocational placement and support services or employment. Guardian of person’s authority: full limited       power to make decisions regarding initiating a petition for termination of marriage. Guardian of person’s authority: full limited       power to receive all notices on behalf of individual . Guardian of person’s authority: full limited       power to act in all proceedings as an advocate of the individual, except the power to enter into a contract that binds the individual or the individual’s property or to represent the individual in any legal proceedings pertaining to the property, unless the guardian of the person is also the guardian of the estate. Guardian of person’s authority: full limited       power to apply for protective placement or for commitment. Guardian of person’s authority: full limited       power to have custody of the individual, if an adult, and the power to have care, custody, and control of the individual, if a minor. Guardian of person’s authority: full limited       other specific power(s):       See attached. GN-3160 10/06 Report of Guardian ad Litem (Guardianship Due to Incompetency) §§54.40, 54.42 and 55.10(4)(b), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 4 Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 4 of 4 Case No. D. Appointment of guardian of the estate and extent of powers Appoint a guardian of the estate with: 1. duties under §54.19; 2. standard powers under §54.20(1), and 3. powers that do not require court approval under §54.20(3) Guardian of estate’s authority: full limited       Authorize the guardian of the estate to exercise additional powers requiring court approval under §54.20(2), other than to make gifts, as follows:       Dispense with bond and order deposit of individual’s funds of $100,000 or less in an insured account of a bank, credit union, savings bank or savings and loan association in the name of the guardian and the ward, and payable only upon further order of the court. Dispense with an appointment of a guardian of the estate and transfer the individual’s funds of $50,000 or less under one of the alternatives for small estates under §54.12(1), WI Statutes, as follows:       15. GUARDIANSHIP, PROTECTIVE PLACEMENT, PROTECTIVE SERVICES. It is my opinion that the court: should should not appoint a guardian of the person. should should not appoint a guardian of the estate with bond of $       . without bond. should should not approve protective placement. should should not approve protective services. should find that the least restrictive placement consistent with the individual's needs and, if the individual is developmentally disabled, the most integrated setting appropriate to the needs of the individual, is a: group home. foster home. community based residential facility. nursing facility. intermediate care facility. other:       in an unlocked unit. in a locked unit because:       16. SUITABILITY AND FITNESS OF PROPOSED GUARDIAN My recommendation to the court regarding the fitness, suitability and the statement of acts of the proposed guardian, stand-by guardian, any other person seeking to be appointed as guardian is: NAME SUITABILITY & FITNESS COMMENTS ON STATEMENT OF ACTS TYPE OF GUARDIAN       Yes No       person estate co-guardian standby       Yes No       person estate co-guardian standby       Yes No       person estate co-guardian standby 17 . Additional comments:       See attached. Distribution: Original – Court Copies – Petitioner Petitioner’s Attorney Signature of Guardian ad Litem       Name Printed or Typed       Date       State Bar Number GN-3160 10/06 Report of Guardian ad Litem (Guardianship Due to Incompetency) §§54.40, 54.42 and 55.10(4)(b), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 4