Fill and Sign the Washington Personal Care Form

Superior Court of Washington County of In the Guardianship of: _______________________________, Incapacitated Person No. Initial Personal Care Plan (PCP) I. ASSESSMENT Check all that apply to the Incapacitated Person in each category: 1.1 Housing Composition : 1.2 Primary Means of Transportation : [ ] Lives Alone [ ] Own Car [ ] Lives with Spouse [ ] Public Transportation [ ] Lives with Children [ ] Friend/Relative [ ] Lives with Relative [ ] Other:_______________________ [ ] Lives with Non-Relative [ ] Other: ______________________ 1.3 Living Arrangement : 1.4 If Lives in Home – Services Needed: [ ] Home Owner [ ] None [ ] Renter [ ] Chore Services (household chores) [ ] Adult Family Home [ ] Other: _____________________________ [ ] Cong. Care Facility ___________________________________ [ ] Nursing Home ___________________________________ [ ] Senior Housing [ ] Other: ___________________________ Initial Personal Care Plan (PCP) - Page 1 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1) 1.5 Functional Limitation : 1.6 Prosthetic Devices : [ ] Walker/Cane [ ] None [ ] Speech [ ] Wheelchair [ ] Hearing [ ] Hearing Aid [ ] Vision [ ] Artificial Limb [ ] Walking [ ] Dentures 1.7 Needs Assistance For : [ ] Eating [ ] Essential shopping with Incapacitated Person [ ] Toileting [ ] Essential shopping for Incapacitated Person [ ] Ambulation [ ] Meal Preparation [ ] Transfer [ ] Laundry [ ] Positioning [ ] Facilities in Home [ ] Personal Hygiene [ ] Facilities out of Home [ ] Dressing [ ] Housework [ ] Bathing [ ] Travel to Medical Services [ ] Self Medication 1.8 Needs Assistance to Leave Home : [ ] Yes [ ] No Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. Circle one of the following codes for each item listed below: Y=Yes; N=No; CD= Cannot Determine. Y N CD 1.9 Incapacitated Person’s Ability To Handle Emergencies : Knows what to do in the event of a fire. Y N CD Knows what to do in case of medical emergency (doctor, ambulance). Y N CD Knows what to do in the event of a break-in or robbery. Y N CD Knows how to call emergency telephone services (911). Y N CD 1.10 Incapacitated Person Knows How To Seek Help From Others To Keep Supply Of Goods and Obtain Services (Housekeeper, Lawyer, Community Services): Y N CD Initial Personal Care Plan (PCP) - Page 2 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1) 1.11 Incapacitated Person’s Financial Abilities : Able to collect benefit, retirement, social security, V.A. benefits. Y N CD Able to maintain checking accounts with balance greater than $_______. Y N CD Able to pay monthly bills for rent, utilities, etc. Y N CD Willing and able to spend money for necessary goods and services, i.e. food, clothing, sundries, etc. Y N CD Able to seek help in money management. Y N CD Able to manage funds. Y N CD If someone other than the guardian of the person is guardian of the estate, or if the Incapacitated Person’s assets are under the control of a trustee, provide the following information: List sources of income and/or resources to pay for monthly costs and care of the Incapacitated Person: _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. Estimated monthly costs and care of the Incapacitated Person: Housing: $ ____________ Other: $ ____________ Food: $ ____________ ________________ $ ____________ Utilities: $ ____________ ________________ $ ____________ Clothing and Laundry: $ ____________ ________________ $ ____________ Medical: $ ____________ ________________ $ ____________ Recreational: $ ____________ ________________ $ ____________ Insurance: $ ____________ ________________ $ ____________ 1.12 Incapacitated Person’s Psychological/Social/Cognitive Functioning : Y=Yes; N=No; CD= Cannot Determine. Y N CD A. Disorientation : Able to relate to person, place or time: Y N CD B. Memory Impairment : Can remember events occurring within the hour: Y N CD Can remember events occurring within the day: Y N CD Can remember events occurring within the week: Y N CD C. Impaired Judgment : Able to make appropriate decisions, solve problems, and respond to major life changes: Y N CD D. Communications : Able to understand what is being said: Y N CD Able to express thoughts and needs: Y N CD Initial Personal Care Plan (PCP) - Page 3 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1) E. Wandering : Moves about aimlessly, or in pursuit of an unobtainable goal: Y N CD F. Verbally Abusive Behavior : Threatens/berates others, yells, uses foul language, etc.: Y N CD G. Disruptive or Inappropriate Behavior : Makes excessive demands for attention, takes another’s possessions, disrobes in front of others, inappropriate sexual behavior, etc.: Y N CD H. Assaultive or Combative Behavior : Throws objects, strikes or punches, makes dangerous maneuvers with wheelchair, etc.: Y N CD I. Danger to Self : Indicated by self-neglect or harm, suicidal thoughts or attempts, etc.: Y N CD J. Other Impairments in Thought, Moods, Behavior : Please Describe: ___________________________________________________________________. II. Care Plan 2.1 Incapacitated Person’s Residence _______________________________________________________________________________ Facility Name (if applicable) ________________________________________________________________________________ Address ________________________________________________________________________________ *Phone: 2.2 Plan for Chore Services Provided in Home (if necessary) _________________________________________________________________________________ _________________________________________________________________________________ ________________________________________________________________________________. 2.3 Plan for nursing services and other medical or personal care services provided in home, adult family home, or congregate care facility (if necessary): _________________________________________________________________________________ ________________________________________________________________________________. Initial Personal Care Plan (PCP) - Page 4 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1) 2.4 Plan for other services, including rehabilitative, educational, social, and recreational services : _______________________________________________________________________________ _______________________________________________________________________________. 2.5 Treating Physician : Name Address Phone/Fax Number _______________________ ______________________________ ______________________ _______________________ ______________________________ ______________________ _______________________ ______________________________ ______________________ 2.6 Current Medications : ________________________________________________________________________________ ________________________________________________________________________________. 2.7 Other Professionals Assisting Incapacitated Person : Name Service Provided Address Phone/Fax Number _____________________ _________________ _________________________ ________________ _____________________ _________________ _________________________ ________________ _____________________ _________________ _________________________ ________________ 2.8 Other Significant Persons : Name/Relationship to Incapacitated Person Address Phone/Fax Number ________________________________________ _________________________ ________________ ________________________________________ _________________________ ________________ ________________________________________ _________________________ ________________ 2.9 Plan for Financial Management : (i.e. Person(s) responsible to receive income and pay monthly costs and care of the Incapacitated Person.) _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. I 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 Guardian Print Name of Guardian [ ]WSBA [ ]CPG# ____________________________________ _____________________________________ Address City, State, Zip Code ____________________________________ ______________________________________ *Telephone/Fax Number Email Address Initial Personal Care Plan (PCP) - Page 5 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1) *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 . Initial Personal Care Plan (PCP) - Page 6 of 6 WPF GDN 04.0700 (01/2009) RCW 11.92.043(1)