[Houston County Commission] guardianship_annual

A. Information About Incapacitated Person (Ward)

Incapacity

Intellectually disabled

Chronic Mental Illness

Alzheimers Dementia

Stroke

Head Injury

Other

Residence

Guardians Home

Wards Home

Nursing Home

Other

Name of Nursing Home or Other Facility (If Applicable)

Date Ward Moved to present residence

Has Ward changed residences within last 12 months?

Yes

If Yes, state the reason for the move

B. Information About Guardian of the Person

Guardian's Physical Address

Guardian's Mailing Address

Guardian's Email Address

Has Guardian's Address Changed in last year?

Yes

Relationship To Ward

Family

Friend

No 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

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:

Describe Physician Treatment

Psychiatrist's or Psychologists Name

Describe Psychologist Treatment

Social or other Case Worker Name

Describe Social Worker Evaluation

Describe Dentist Treatment

Describe Other Treatment

Does Ward have a primary doctor

Yes

Primary Doctor's Name

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

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

Does the Ward have a Trust Account?

Yes

Does the Ward receive Supplemental Security Income (SSI)?

Yes

If Yes, how much per month?

Does Ward receive Social Security benefits?

Yes

If Yes, how much per month?

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

Upload copy of Power of Attorney to this Annual Report

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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

If Yes, please Describe

My powers as Guardian Should

Remain Same

Decrease

Increase

Decreased as follows:

Increased as follows:

Please Upload a recent photograph of the Ward to this annual report

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