Gc 335 Form PDF Details

Understanding the intricacies and significance of the GC-335 form is crucial for individuals navigating the conservatorship process within the California Superior Court system. This form, titled "Capacity Declaration—Conservatorship," serves as a fundamental tool for physicians, psychologists, or religious healing practitioners to assess the mental capacity of a proposed conservatee. It is designed to provide the court with detailed information concerning the individual's ability to attend court hearings, make informed medical treatment decisions, and comprehend their own mental health condition, including any neurocognitive disorders such as dementia. Through items like evaluating alertness, information processing abilities, and mood modulation, the form meticulously outlines the proposed conservatee’s mental functions. This assessment is critical in determining whether an individual requires a conservator to manage their personal affairs and medical decisions, thereby safeguarding their well-being and ensuring they receive appropriate care. The GC-335 form, which demands rigorous completion in every case, embodies a structured approach to addressing the sensitive issue of conservatorship, simultaneously protecting the rights and dignity of individuals who may not be fully capable of caring for themselves or making informed decisions.

QuestionAnswer
Form NameGc 335 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesgc 335 capacity declaration conservatorship, ca capacity declaration, gc 335 declaration, capacity declaration conservatorship

Form Preview Example

and state the facts in Attachment 5.)
b.

GC-335

ATTORNEY OR PARTY WITHOUT ATTORNEY

STATE BAR NUMBER:

FOR COURT USE ONLY

 

 

 

 

NAME:

 

 

 

FIRM NAME:

 

 

 

STREET ADDRESS:

 

 

 

CITY:

STATE:

ZIP CODE:

 

TELEPHONE NO.:

FAX NO.:

 

 

E-MAIL ADDRESS:

 

 

 

ATTORNEY FOR (name):

 

 

 

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

 

 

 

 

 

 

STREET ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

CITY AND ZIP CODE:

 

 

 

 

 

 

 

 

 

 

 

 

BRANCH NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSERVATORSHIP OF THE

 

PERSON

 

 

ESTATE

OF (Name):

 

 

 

 

 

 

 

 

 

CONSERVATEE

 

 

PROPOSED CONSERVATEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NUMBER:

 

 

 

 

CAPACITY DECLARATION—CONSERVATORSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER

The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply):

A.

 

 

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

1.

(Name):

 

 

 

 

 

 

 

 

 

 

 

2. (Office address and telephone number):

 

 

 

 

 

 

3.

I am

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

a California-licensed

 

 

physician

 

 

 

psychologist acting within the scope of my license

 

 

 

 

 

 

 

 

with at least two years' experience in diagnosing and treating major neurocognitive disorders (including dementia). 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.)

4.(Proposed) conservatee (name):

a. I last saw the (proposed) conservatee on (date):

b. The (proposed) conservatee

 

is

 

is NOT

a patient under my continuing treatment and care.

ABILITY TO ATTEND COURT HEARING

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) until (date):

(4) Supporting facts (State facts in the space below or check this box

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)

 

 

Page 1 of 3

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

GC-335

CONSERVATORSHIP OF THE

 

PERSON

CONSERVATEE

ESTATE OF (Name):

PROPOSED CONSERVATEE

CASE NUMBER:

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.

(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.)

A. Alertness and attention

(1)Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor)

a

 

b

 

c

 

d

(2) Orientation (types of orientation impaired)

e

a

a

a

a

b

b

b

b

c

c

c

c

d

d

d

d

e e e e

Person

Time (day, date, month, season, year)

Place (address, town, state)

Situation ("Why am I here?")

(3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle)

a

b

c

d

e

B.Information processing. Ability to:

(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

ii.

Long-term memory

a

iii.

Immediate recall

a

b

b

b

c

c

c

d

d

d

e

e

e

(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

(7) Reason logically

c

d

e

a

b

c

d

e

C.Thought disorders

(1)Severely disorganized thinking (rambling thoughts; nonsensical, incoherent, or nonlinear thinking)

a

 

b

 

c

 

d

(2)Hallucination (auditory, visual, olfactory)

a b c d

e

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]

CAPACITY DECLARATION—CONSERVATORSHIP

Page 2 of 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GC-335

CONSERVATORSHIP OF THE

 

 

PERSON

 

 

ESTATE

OF (Name):

CASE NUMBER:

 

 

CONSERVATEE

 

 

PROPOSED CONSERVATEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. (continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Ability to modulate mood and affect. The (proposed) conservatee

 

 

has

 

 

does NOT have a pervasive and

 

 

 

 

persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If so, complete

 

 

 

 

I have no opinion.

 

 

 

 

 

 

remainder of item 6D.)

 

 

 

 

 

 

 

 

 

(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 a

Anxiety a

Fear a

Panic a

b

b

b

b

c

c

c

c

Euphoria a

Depression a

Hopelessness a

Despair a

b

b

b

b

c

c

c

c

Helplessness a

Apathy a

Indifference a

b

b

b

c

c

c

E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A–6D

(1)

(2)

do NOT vary substantially in frequency, severity, or duration.

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)

 

 

GC-335 [Rev. January 1, 2019]

CAPACITY DECLARATION—CONSERVATORSHIP

Page 3 of 3

For your protection and privacy, please press the Clear This Form button after you have printed the form.

Print this form Save this form

Clear this form

How to Edit Gc 335 Form Online for Free

You are able to fill out california capacity declaration form easily with the help of our PDFinity® online PDF tool. FormsPal is committed to making sure you have the best possible experience with our editor by constantly introducing new capabilities and upgrades. Our editor has become even more intuitive as the result of the latest updates! Now, working with documents is simpler and faster than before. Here is what you would need to do to get started:

Step 1: Just hit the "Get Form Button" in the top section of this webpage to start up our pdf file editor. There you'll find everything that is required to work with your file.

Step 2: With this state-of-the-art PDF tool, it's possible to do more than simply fill out blank fields. Try each of the functions and make your forms seem great with custom text put in, or fine-tune the original input to excellence - all comes along with an ability to add stunning pictures and sign it off.

Be attentive while filling in this pdf. Ensure that all necessary blank fields are filled in correctly.

1. To get started, once completing the california capacity declaration form, start in the page containing next fields:

Stage # 1 in completing declaration conservatorship

2. Once the last part is filled out, go to type in the applicable information in these - If more than one item is checked, GENERAL INFORMATION, Name Office address and telephone, I am a, a Californialicensed, physician, psychologist acting within the, with at least two years experience, an accredited practitioner of a, Proposed conservatee name a I last, The proposed conservatee, is NOT a patient under my, ABILITY TO ATTEND COURT HEARING A, a b, and The proposed conservatee is able.

declaration conservatorship conclusion process clarified (step 2)

3. The next step will be hassle-free - complete every one of the empty fields in CONSERVATORSHIP OF THE OF Name, PERSON, ESTATE, CASE NUMBER, CONSERVATEE, PROPOSED CONSERVATEE, EVALUATION OF PROPOSED, Note to practitioner This form is, Instructions for items AC Check, A Alertness and attention, Levels of arousal lethargic, Orientation types of orientation, Person, Time day date month season year, and Place address town state to conclude the current step.

The way to fill out declaration conservatorship stage 3

As to Note to practitioner This form is and A Alertness and attention, be certain you do everything right here. Both of these could be the key ones in this document.

4. Your next paragraph requires your attention in the subsequent places: past hours, i Shortterm memory, ii Longterm memory, iii, Immediate recall, Understand and communicate either, instructions use words correctly, Recognize familiar objects and, Understand and appreciate, Reason using abstract concepts, idiomatic expressions or proverbs a, Plan organize and carry out, inability to break complex tasks, Reason logically, and C Thought disorders. Make certain to fill out all needed details to go further.

Reason using abstract concepts, Understand and communicate either, and idiomatic expressions or proverbs a inside declaration conservatorship

5. Now, the following last portion is what you have to finish prior to finalizing the PDF. The blank fields in this case include the next: Hallucination auditory visual, Delusions demonstrably false, Uncontrollable or intrusive, Continued on next page, GC Rev January, CAPACITY DECLARATIONCONSERVATORSHIP, and Page of.

declaration conservatorship completion process detailed (step 5)

Step 3: Prior to finalizing this file, make certain that all form fields are filled out the correct way. As soon as you are satisfied with it, click on “Done." Download your california capacity declaration form after you join for a free trial. Immediately use the pdf form within your personal account page, along with any edits and adjustments conveniently kept! At FormsPal.com, we aim to make sure that all of your details are stored protected.

Gc 335 Form isn’t the one you’re looking for?

Related Documents