2. INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS
A. Alertness/Level of Consciousness
Overall Impairment: |
None |
Mild |
Moderate |
Severe |
Non-Responsive |
B. Memory and Cognitive Functioning (e.g., memory, comprehension, reasoning, judgment, planning, insight)
Overall Impairment: |
None |
Mild |
Moderate |
Severe |
C. Emotional and Psychiatric Functioning (e.g., mood, anxiety, psychotic, substance use and other disorder)
Overall Impairment: |
None |
Mild |
Moderate |
Severe |
Describe how impairments in A, B, and/or C cause the individual to have an inability to receive and evaluate information or make or communicate decisions:
3.1GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR PHYSICAL HEALTH, SAFETY, AND SELF-CARE
If seeking guardianship of the person, complete section 3.1. If seeking only a conservatorship, do not complete this section. Limited Guardianship is preferred by the Court; describe how the guardianship may be limited. Describe how the assessment was performed and give specific examples.
A.Areas in which the individual is able to meet the essential requirements for physical health, safety, and self-care:
Describe the individual's retained abilities and adaptive behavior for physical health, safety, self-care for which the guardianship may be limited (e.g., ability to manage ADL's and IADL's such as health, hygiene, home, communication, driving, leisure, social; functioning in the community; ability to express treatment choices and make medical decisions; ability to complete any or some legal transactions).
B.Areas in which the individual is unable to meet essential requirements for physical health, safety, or self-care: Describe the impairments in physical health, safety, and self-care for which the individual requires a guardian.
C.If individual is unable to make any decisions for him or herself or is unable to meet any essential requirements for physical health, safety, and self-care (i.e. requires a full guardianship), describe why: