Form CI-12 "Report to the Court on the Status of Conservatee" - County of San Joaquin, California

What Is Form CI-12?

This is a legal form that was released by the Superior Court - County of San Joaquin, California - a government authority operating within California. The form may be used strictly within County of San Joaquin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Superior Court - County of San Joaquin, California;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CI-12 by clicking the link below or browse more documents and templates provided by the Superior Court - County of San Joaquin, California.

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SUPERIOR COURT INVESTIGATORS
PHONE: (209) 992-5696
SUPERIOR COURT OF SAN JOAQUIN COUNTY
In The Conservatorship of:
C
N
ASE
UMBER
REPORT TO THE COURT ON THE STATUS OF CONSERVATEE
I, _____________________________am the Conservator of the above-named Conservatee and my status report is as follows:
1. Present age of the Conservatee: ____________
Conservatee’s Date of birth: ______________
2. Current Living arrangements of the Conservatee:
A.
Name of care facility/board and care: _________________________________________
B.
Current address: _________________________________________________________
_________________________________________________________
C.
Phone number of Conservatee: __________________________________________________
D.
The Conservatee’s residence is
own home/apartment
Conservator’s home/apartment
nursing home
hospital or medical facility
boarding home
relative’s home (relationship) ________________
other (specify)__________
E.
The Conservatee has been in the present residence since (date):_____________. If moved within the past year,
state reason(s) for change: ____________________________________________
F.
I rate the Conservatee living arrangement as
Excellent
Average
Below average
(Explain)_____________________________________________________________________
G.
I believe the Conservatee is:
content with the living situation
unhappy with the living situation
H.
I recommend a more suitable living arrangement for the adult as follows:
________________________________________________________________________________
________________________________________________________________________________
3. Physical Health
A.
I believe that the Conservatee’s current physical condition is
Excellent
Good
Fair
Poor
B.
During the past year the Conservatee’s physical condition has:
remained about the same
improved (Explain) _________________________________________________
worsened (Explain)_________________________________________________
(
C.
During the past year the Conservatee received the following medical treatment;
Include check-ups and dental):
Date
Ailment
Type of Treatment
Doctor’s Name
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
STATUS REPORT ON CONSERVATEE
Form Adopted for Optional Use
CONFIDENTIAL
Superior Court of California, County of San Joaquin
Form – CI-12
Effective 01/01/2011
SUPERIOR COURT INVESTIGATORS
PHONE: (209) 992-5696
SUPERIOR COURT OF SAN JOAQUIN COUNTY
In The Conservatorship of:
C
N
ASE
UMBER
REPORT TO THE COURT ON THE STATUS OF CONSERVATEE
I, _____________________________am the Conservator of the above-named Conservatee and my status report is as follows:
1. Present age of the Conservatee: ____________
Conservatee’s Date of birth: ______________
2. Current Living arrangements of the Conservatee:
A.
Name of care facility/board and care: _________________________________________
B.
Current address: _________________________________________________________
_________________________________________________________
C.
Phone number of Conservatee: __________________________________________________
D.
The Conservatee’s residence is
own home/apartment
Conservator’s home/apartment
nursing home
hospital or medical facility
boarding home
relative’s home (relationship) ________________
other (specify)__________
E.
The Conservatee has been in the present residence since (date):_____________. If moved within the past year,
state reason(s) for change: ____________________________________________
F.
I rate the Conservatee living arrangement as
Excellent
Average
Below average
(Explain)_____________________________________________________________________
G.
I believe the Conservatee is:
content with the living situation
unhappy with the living situation
H.
I recommend a more suitable living arrangement for the adult as follows:
________________________________________________________________________________
________________________________________________________________________________
3. Physical Health
A.
I believe that the Conservatee’s current physical condition is
Excellent
Good
Fair
Poor
B.
During the past year the Conservatee’s physical condition has:
remained about the same
improved (Explain) _________________________________________________
worsened (Explain)_________________________________________________
(
C.
During the past year the Conservatee received the following medical treatment;
Include check-ups and dental):
Date
Ailment
Type of Treatment
Doctor’s Name
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
STATUS REPORT ON CONSERVATEE
Form Adopted for Optional Use
CONFIDENTIAL
Superior Court of California, County of San Joaquin
Form – CI-12
Effective 01/01/2011
4. Mental Health
A.
I believe the Conservatee’s current mental condition is
Excellent
Good
Fair
Poor
B.
During the past year the Conservatee’s mental condition has:
remained about the same.
improved (Explain) _________________________________________________________
worsened (Explain) ________________________________________________________
C.
During the past year, treatment or evaluation by a psychologist or social worker:
was provided
was not provided __________________________________________________
D.
IF conservatee is a client of Valley Mountain Regional Center please provide:
(Case Manager Name):_________________________________ (Phone Number):___________________
5. Social Activities/Services
A. The conservatee’s social condition is
Excellent
Good
Fair
Poor
B. During the past year, the Conservatee’s social condition has:
remained about the same
improved (Explain) ______________________________________
C. IF conservatee participates in a day-program please provide
Name of Program: ______________________________________________
Address: _____________________________________________________
Phone Number: ________________________________________________
D. During the past year, the Conservatee has participated in the following activities:
Recreational _____________________________________________________________________
Educational ______________________________________________________________________
Social ___________________________________________________________________________
Occupational _____________________________________________________________________
Other organizations/programs the Conservatee participates in; describe: ______________________
___________________________________________________________________________________
If the conservatee does not attend a day-program, please explain why: ________________________
____________________________________________________________________________________
6. List of Visits
Please check this box if the conservatee lives with the conservator.
A. The last visit to the conservatee was on __________. During the past year, I visited the Conservatee as
follows:_____________________________________________________________________________
_____________________________________________________________________________________
B. The average amount of time I spent on each visit was: _______________________________________
7. I intend to change or I request the court to be able to change the following:
A. The Conservatee’s living arrangement (describe);___________________________________________
______________________________________________________________________________________
B. The current financial management of estate including the sale of any assets (describe);
______________________________________________________________________________________
______________________________________________________________________________________
8. The conservatorship
should be
should not be continued because:
______________________________________________________________________________________
______________________________________________________________________________________
9. A. I
am the Conservator of the Person Only for the Conservatee.
B. I
am the Conservator of the Person and Estate and my accounting will be filed separately.
___________________________________
Address: ___________________________
Check if
new address
(Signature)
_____________________________________
Phone:
___________________________
Check if
_________________________________________________
new phone #
(Date)
STATUS REPORT ON CONSERVATEE
CONFIDENTIAL
CI-12 (01/11)
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