Fill and Sign the California Dementia Attachment to Capacity Declaration Conservatorship Form

9. It is my opinion that the (proposed) conservatee a major neurocognitive disorder (such as dementia) as defined in the current edition of Diagnostic and Statistical Manual of Mental Disorders. Form Adopted for Mandatory Use Judicial Council of California GC-335A [Rev. January 1, 2019]MAJOR NEUROCOGNITIVE DISORDER ATTACHMENT TO CAPACITY DECLARATION—CONSERVATORSHIP Probate Code, §§ 811, 2356.5 www.courts.ca.govPage 1 of 1 The (proposed) conservatee HAS the capacity to give informed consent to the administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia). ATTACHMENT TO FORM GC-335, CAPACITY DECLARATION—CONSERVATORSHIP, ONLY FOR (PROPOSED) CONSERVATEE WITH A MAJOR NEUROCOGNITIVE DISORDER The (proposed) conservatee needs or would benefit from the administration of the medications listed in item 9b(1) because (discuss reasons; continue on Attachment 9b(5) if necessary): (SIGNATURE OF DECLARANT) Date: (TYPE OR PRINT NAME) CONSERVATORSHIP OF THE CASE NUMBER: GC-335A PERSON ESTATE OF (name): CONSERVATEE PROPOSED CONSERVATEE HAS does NOT have a. Placement of (proposed) conservatee. (If the (proposed) conservatee requires placement in a secured-perimeter residential care facility for the elderly, please complete items 9a(1)–9a(5).) The (proposed) conservatee needs or would benefit from placement in a restricted and secure facility because (state reasons; continue on Attachment 9a(1) if necessary): (1) The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of form GC-335, include (describe; continue on Attachment 9b(2) if necessary): (2) (3) The (proposed) conservatee does NOT have the capacity to give informed consent to the administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia). The deficits in mental function assessed in item 6 of form GC-335 and described in item 9b(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of giving consent to the administration of medications for the care and treatment of major neurocognitive disorders (including dementia). (4) (5)The (proposed) conservatee HAS the capacity to give informed consent to this placement. (3) The (proposed) conservatee does NOT have the capacity to give informed consent to this placement. The deficits in mental function assessed in item 6 of form GC-335 and described in item 9a(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of giving consent to placement in a restricted and secure environment. (4) A locked or secured-perimeter facility the least restrictive environment appropriate to the needs of the (proposed) conservatee. (5) is is NOT b. Administration of medications. (If the (proposed) conservatee requires administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia), please complete items 9b(1)–9b(5).) For the reasons stated in item 9b(5), the (proposed) conservatee needs or would benefit from the following medications appropriate to the care and treatment of major neurocognitive disorders (including dementia) (list medications; continue on Attachment 9b(1) if necessary): (1) The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of from GC-335, include (describe; continue on Attachment 9b(2) if necessary): (2) 10. 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. Print this form Save this form Clear this form For your protection and privacy, please press the Clear This Form button after you have printed the form.