Fill and Sign the Periodic Personal Care Plan Spokane County Form

Periodic Personal Care Plan (PCP) - Page 1 of 2WPF GDN 05.0700 (01/2009) RCW 11.92.043, .050Superior Court of WashingtonCounty ofIn the Guardianship of:_______________________________, Incapacitated PersonNo. Periodic Personal Care Plan(PCP)The [ ] Full [ ] Limited Guardian of the Person, respectfully submits the following Personal Care Plan:1.Custody and Residence of Incapacitated Person The Incapacitated Person is now _____ years of age. He/She presently resides at (name of facility, if applicable, and address): ________________________________________________ __________________________________. The Guardian believes that he/she is receiving satisfactory care, and should continue to reside there.2.Description of Services or Programs Incapacitated Person Receives The Incapacitated Person receives the following services or programs: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. 3. Physical and Medical Status and Need of Incapacitated Person The physical and medical status and needs of the Incapacitated Person are as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. 4.Mental and Emotional Status of Incapacitated Person The mental and emotional status of the Incapacitated Person is as follows: ______________________________________________________________________________ ______________________________________________________________________________. Periodic Personal Care Plan (PCP) - Page 2 of 2WPF GDN 05.0700 (01/2009) RCW 11.92.043, .0505.Description of Functional Abilities of the Incapacitated Person The following is a description of the Incapacitated Person’s abilities to perform and/or assist in the activities of daily living. ____________________________________________________________________________ ____________________________________________________________________________. 6.Guardian’s Specific Plan for Meeting the Identified and Emerging Personal Care Needs of the Incapacitated Person The Guardian’s specific plan for meeting the identified and emerging personal care needs of the Incapacitated Person is as follows: _____________________________________________________________________________ _____________________________________________________________________________. 7.Contact Information for Facility or Home of Incapacitated Person, Guardian and Standby Guardian Facility/Home Contact Guardian Standby Guardian Full Name Mailing AddressCity, State, Zip *Telephone NumberI certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.Signed at (city) ___________________, (state) ___________ on (date) _______________________._________________________________ ________________________ _____________________ Signature of GuardianPrint Name of Guardian [ ] WSBA No. [ ] CPG#__________________________________ ______________________________________________AddressCity, State, Zip Code_________________________________________________________________________________*Telephone/Fax NumberEmail Address*If you do not want your personal phone number on this public form, you may list your telephone number on a separate form which may be available to parties and the court, as well as its staff and volunteers, but will not be made available to the public. Use Form WPF GDN 03.0100, Guardianship Confidential Information form (Telephone Numbers), for this purpose.Note: Do not attach records produced and signed by a health care provider to this form.