Section 1 of 1 in this document
A. Information About Incapacitated Person (Ward)
Wards Name
*
Wards Age
*
Wards Date of Birth
*
Incapacity
Intellectually disabled
Chronic Mental Illness
Alzheimers Dementia
Stroke
Head Injury
Other
Other:describe
Residence
Guardians Home
Wards Home
Nursing Home
Other
Name of Nursing Home or Other Facility (If Applicable)
*
Residence Address
*
Residence Phone#
*
Date Ward Moved to present residence
*
Has Ward changed residences within last 12 months?
Yes
No
If Yes, state the reason for the move
B. Information About Guardian of the Person
Guardian's Name
*
Guardian's Physical Address
*
Guardian's Mailing Address
*
Guardian's Email Address
*
Has Guardian's Address Changed in last year?
Yes
No
Guardian Home Phone
*
Guardian Work Phone
*
Guardian Cell Phone
*
Relationship To Ward
Family
Friend
No Relation
Family Relation
C. Visitation/Phone Contact
Live With Guardian
Does
Does Not
List date of your last personal visit
If you have not visited the Ward frequently, have you had telephone contact?
Yes
No
How often is telephone contact?
List date of last telephone contact
Who is the main telephone contact?
D. Information About Ward's Medication
During the past year, Ward's mental health has
Remained The Same
Improved
Deteriorated
Describe mental health
*
During the past year, Ward's physical health has (Describe)
*
During the past year, Ward has been treated or evaluated by the following:
Physicians Name
*
Describe Physician Treatment
*
Psychiatrist's or Psychologists Name
*
Describe Psychologist Treatment
*
Social or other Case Worker Name
*
Describe Social Worker Evaluation
*
Dentist's Name
*
Describe Dentist Treatment
*
Other Name
*
Describe Other Treatment
*
Does Ward have a primary doctor
Yes
No
Primary Doctor's Name
Doctor's Address
Doctor's Telephone
I believe my Ward has the following unmet medical needs
*
What is being done to address these unmet needs?
*
E. Information About Ward's Social Conditions
Activities
Educational
Social
Occupational
NoneAvailable
Ward Refuses
Recreational
Recreational
Educational
Social
Occupational
None Available
Ward refuses or is unable to participate
What accomplishments, successes, goals, if any had the Ward achieved this year?
*
I believe my Ward has the following unmet social needs?
*
What is being done to address these unmet needs?
*
F. Information About Ward's Living Conditions
I rate my Ward's living arrangements as: (Check One)
Excellent
Average
Below Average
If Below Average is marked, please explain
I Believe my Ward is
Content
Unhappy
I believe my Ward has the following unmet basic needs
*
What is being done to address these unmet needs?
*
G. Information About Ward's Assets and Income
Does the Ward have a Conservator of the Estate?
Yes
No
Does the Ward have a Trust Account?
Yes
No
Does the Ward receive Supplemental Security Income (SSI)?
Yes
No
If Yes, how much per month?
List Name of Payee
Does Ward receive Social Security benefits?
Yes
No
If Yes, how much per month?
List Name of Payee
List source and amount of any other benefits you receive on Ward's behalf?
*
List any assets of Ward, other than personal effects, that you possess and that you have not listed on Guardian of the Estate's Annual Account
*
Do you handle Ward's assets using a Power of Attorney?
Yes
No
Upload copy of Power of Attorney to this Annual Report
H. Additional Information
Has Ward regained capacity to make decisions as would a reasonable prudent person in any of the areas over which you have been given power to make decisions for Ward as Guardian?
Yes
No
If Yes, please Describe
My powers as Guardian Should
Remain Same
Decrease
Increase
Decreased as follows:
Increased as follows:
AdditionalInfo1
*
Please Upload a recent photograph of the Ward to this annual report
Email
Email
Email
disregard this