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Form Adopted for Mandatory Use Judicial Council of California GC-335 [Rev. January 1, 2019]CAPACITY DECLARATION—CONSERVATORSHIP Probate Code, §§ 811, 813, 1801, 1825, 1881, 1910, 2356.5 www.courts.ca.gov Page 1 of 3 SUPERIOR COURT OF CALIFORNIA, COUNTY OF BRANCH NAME: CITY AND ZIP CODE: STREET ADDRESS: MAILING ADDRESS: CONSERVATEE PROPOSED CONSERVATEE FOR COURT USE ONLY CASE NUMBER: CAPACITY DECLARATION—CONSERVATORSHIP ATTORNEY OR PARTY WITHOUT ATTORNEY STATE: ZIP CODE: CITY: STREET ADDRESS: FIRM NAME: NAME: TELEPHONE NO.: FAX NO.: E-MAIL ADDRESS: ATTORNEY FOR ( name): STATE BAR NUMBER: GC-335 TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER A. 1. ABILITY TO ATTEND COURT HEARING CONSERVATORSHIP OF THE OF (Name): PERSON ESTATE The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply): is able to attend a court hearing to determine whether a conservator should be appointed to care for him or her. The court hearing is set for (date): . (Complete item 5, then sign and file page 1 of this form.) B. has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3, and file pages 1 through 3 of this form.) C. has a major neurocognitive disorder (such as dementia) and, if so, (1) whether he or she needs to be placed in a secured- perimeter residential care facility for the elderly, and (2) whether he or she needs or would benefit from medication for the treatment of major neurocognitive disorders (including dementia). (Complete items 6 and 8 of this form and complete form GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and file form GC-335A.) (If more than one item is checked above, sign the last applicable page of this form or, if item C is checked, form GC-335A. File page 1 through the last applicable page of this form; if item C is checked, file form GC-335A as well.) COMPLETE ITEMS 1–4 OF THIS FORM IN EVERY CASE. GENERAL INFORMATION (Name): 2. (Office address and telephone number): 3. I am a. physician psychologist acting within the scope of my license with at least two years' experience in diagnosing and treating major neurocognitive disorders (including dementia). 4. (Proposed) conservatee (name): a. I last saw the (proposed) conservatee on (date): The (proposed) conservatee b. is is NOT a patient under my continuing treatment and care. 5. A court hearing on the petition for appointment of a conservator is set for the date indicated in item A above. (Complete a. or b.) a. The proposed conservatee is able to attend the court hearing. b. Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items below that apply) (1) on the date set (see date in box in item A above). (2) for the foreseeable future. (3) (date): until (4) Supporting facts (State facts in the space below or check this box and state the facts in Attachment 5.) 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) a California-licensed b. an accredited practitioner of a religion that calls for reliance on prayer alone for healing. The (proposed) conservatee is an adherent of my religion and is under my care. (Practitioner may make ONLY the determination in item 5.) GC-335 [Rev. January 1, 2019]Page 2 of 3 CAPACITY DECLARATION—CONSERVATORSHIP GC-335 CASE NUMBER: CONSERVATEE PROPOSED CONSERVATEE CONSERVATORSHIP OF THE OF (Name): PERSON ESTATE 6. EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTIONS Note to practitioner: This form is not a rating scale. It is intended to assist you in recording your impressions of the (proposed) conservatee's mental abilities. Where appropriate, you may refer to scores on standardized rating instruments. A. Alertness and attention a (Instructions for items 6A–6C): Check the appropriate designation as follows: a = no apparent impairment; b = moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = i have no opinion.) (1) Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor) b c d e a (2) Orientation (types of orientation impaired) b c d e Person a b c d e Time (day, date, month, season, year) a b c d e Place (address, town, state) a b c d e Situation ("Why am I here?") a (3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle) b c d e B. Information processing. Ability to: a b c d e (1) Remember (ability to remember a question before answering; to recall names, relatives, past presidents, and events of the past 24 hours) i. Short-term memory a b c d e ii. Long-term memory a b c d e iii. Immediate recall (2) Understand and communicate either verbally or otherwise (deficits reflected by inability to comprehend questions, follow instructions, use words correctly, or name objects; use of nonsense words) a b c d e (3) Recognize familiar objects and persons (deficits reflected by inability to recognize familiar faces, objects, etc.) a b c d e (4) Understand and appreciate quantities (deficits reflected by inability to perform simple calculations)a b c d e (5) Reason using abstract concepts (deficits reflected by inability to grasp abstract aspects of his or her situation or to interpret idiomatic expressions or proverbs) a b c d e (6) Plan, organize, and carry out actions (assuming physical ability) in one's own rational self-interest (deficits reflected by inability to break complex tasks down into simple steps and carry them out) a b c d e (7) Reason logically a b c d e C.Thought disorders (1) Severely disorganized thinking (rambling thoughts; nonsensical, incoherent, or nonlinear thinking) a b c d e (2) Hallucination (auditory, visual, olfactory) a b c d e (3) Delusions (demonstrably false belief maintained without or against reason or evidence)a b c d e (4) Uncontrollable or intrusive thoughts (unwanted compulsive thoughts, compulsive behavior)a b c d e (Continued on next page) GC-335 [Rev. January 1, 2019]Page 3 of 3 CAPACITY DECLARATION—CONSERVATORSHIP GC-335 CASE NUMBER: CONSERVATEE PROPOSED CONSERVATEE CONSERVATORSHIP OF THE OF (Name): PERSON ESTATE 6. (continued) D. Ability to modulate mood and affect. The (proposed) conservatee a pervasive and persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If so, complete remainder of item 6D.) has does NOT have I have no opinion. (Instructions for item 6D): Check the degree of impairment of each inappropriate mood state (if any) as follows: a = mildly inappropriate; b = moderately inappropriate; c = severely inappropriate.) Anger Anxiety a b c a b c Fear a b c Panica b c Euphoria Depression a b c a b c Hopelessness a b c Despair a b c Helplessness Apathya b c a b c Indifference a b c E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A–6D (1) do NOT vary substantially in frequency, severity, or duration. (2) do vary substantially in frequency, severity, or duration (explain; continue on Attachment 6E if necessary): F. (Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g., diagnosis, symptomatology, and other impressions) is stated below stated in Attachment 6F. ABILITY TO CONSENT TO MEDICAL TREATMENT 7. Based on the information above, it is my opinion that the (proposed) conservatee a. has the capacity to give informed consent to any form of medical treatment. This opinion is limited to medical consent capacity. b. lacks the capacity to give informed consent to any form of medical treatment because he or she is either (1) unable to respond knowingly and intelligently regarding medical treatment or (2) unable to participate in a treatment decision by means of a rational thought process, or both. The deficits in the mental functions described in item 6 above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of medical decisions. This opinion is limited to medical consent capacity. (Declarant must initial here if item 7b applies: _____________.) 8. 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) 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.