The following forms shall be used for the purposes of this chapter: STATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF ______ _________________________________________ No. _________________________________________ ESTATE OF _________________________________________ PERSONAL ESTATE ESTIMATED AT $_______________ CITY/TOWN OF ____________ 20__________ _______________________________________ Petitioner hereby petitions the Probate Court of the city/town of _______________________________________ to appoint a limited guardian/guardian for _______________________________________ who currently resides at _______________________________________________________________________ Address, in the city/town of _______________________________________ , and whose date of birth is _________________________________________ . Based upon an assessment conducted by _______________________________________ on _________________________________________ Date, which functional assessment reflects the current level of functioning of _______________________________________ Respondent, it has been determined that _______________________________________ Respondent lacks decision-making ability in one or more of the following areas as indicated: Regarding each area indicated, please describe the specific assistance needed: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Indicate which of the following less restrictive alternatives to guardianship have been explored and deemed inappropriate as indicated: ____ Durable Power of Attorney for Health Care ____ Living Will ____ Power of Attorney ____ Durable Power of Attorney ____ Trusts ____ Joint Property Arrangements ____ Representative Payee ____ Money Management ____ Single Court Transactions ____ Government Benefit and Social Service Programs ____ Housing Options ____ Supported Decision-Making, see chapter 66.13 of title 42 ____ Other Please describe the basis for the determination that the alternative will not meet the needs of the respondent for each alternative explored and deemed inappropriate: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Subscribed and sworn to before me as to the truth of the above facts by ____ in ____ on the ____ day of ____ , 20__ . This notice should be served at once and returned to the clerk of the court. NOTICE STATE OF RHODE ISLAND BY THE PROBATE COURT OF THE ______ OF ______ BY THE COUNTY OF _______________________________________ AND STATE AFORESAID To _______________________________________ Estate or _______________________________________ Docket No. _______________________________________ A petition for Limited Guardianship/Guardianship has been filed in the Probate Court of the city/town of _______________________________________ . _________________________________________ has requested that the Probate Court appoint Petitioner A hearing regarding this Petition shall be held date time _________________________________________ The Petition requests that the Probate Court consider the qualification of the following individual/agency to serve as your limited guardian/guardian: A guardian ad litem will be appointed by the Probate Court to visit you, explain the process and inform you of your rights. You have the right to attend the hearing to contest the petition, to request that the powers of the guardian be limited or to object to the appointment of particular individual/agency limited guardian/guardian. If you wish to contest the petition, you have the right to be represented by an attorney, at state expense, if you are indigent. If the Petition is granted and a limited guardian/guardian is appointed, the Probate Court may give the limited guardian/guardian the power to make decisions about one or more of the following: Your health care; your money; where you live; and with whom you associate. Copies of this Notice will be mailed to: I certify that I hand-delivered and read this Notice to _______________________________________ on the ___________ day of _____________________ , 20___________ . I certify that, as required by Rhode Island General Laws § 33-15-17.1(e), I mailed a copy of this Notice to the following persons, at the addresses listed, on the ___________ day of _____________________ , 20___________ . Subscribed and sworn to before me this ___________ day of _____________________ , 20___________ . Judge of the Probate Court of the _______________________________________ of _______________________________________ this ___________ day of _____________________ , 20___________ . This document will be used by a Probate Court to determine whether to appoint a guardian to assist this individual in some or all areas of decision-making. This document has two parts. Please first complete the part which is right after these instructions, titled Assessment. Then complete the second section, titled Summary. To a physician completing this document: The individual’s treating physician must complete this document. If there is any information of which the treating physician completing this document does not have direct knowledge, he or she is encouraged to make such inquiries of such other persons as are necessary to complete the entire form. Those persons might include other medical personnel such as nurses, or other persons such as family members or social service professionals who are acquainted with the individual. If the physician has received information from others in completing the form, the names of those individuals must be listed on the Summary. To a non-physician completing this document: Professionals or other persons acquainted with the individual being assessed may also complete this document. If there is information of which a non-physician completing this document does not have knowledge, such non-physician may either leave portions of the document blank, or also make inquiries or do such investigation as is necessary to complete the entire document. Again, the names of any individual from whom information is derived should be listed on the Summary. The document must be signed and dated by the person completing it. It does not need to be notarized. THE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON ____________ (DATE) 1. DIAGNOSIS and PROGNOSIS: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 2. MEDICATION (PLEASE LIST): _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ How do the above medications, if any, affect the individual’s decision-making ability? Please explain: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 3. CURRENT NUTRITIONAL STATUS: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (A) Intact; (B) Mild Impairment; (C) Moderate Impairment; (D) Severe Impairment (A) Intact; (B) Mild Impairment; (C) Shifting/Wandering; (D) Delirium; (E) Unresponsive (A) Intact; (B) Able to Make Most Decisions; (C) Impaired; (D) Gross Impairment (A) Intact (B) Sensory Deficits (Hearing/Speech/Sight) (C) Impairment In Comprehension/Speech: Mild/Moderate/Severe (D) Completely Unresponsive (A) ANXIETY/DEPRESSION: (1) None (2) History of Anxiety/Depression (3) Moderate Symptoms of Anxiety/Depression (4) Severe symptoms with sleep/appetite/energy disturbance (5) Suicide/Homicidal (B) OTHER: (1) Suspiciousness/Belligerence/Explosiveness (2) Delusions/Hallucinations (3) Unresponsive If you circled any of the above, other than (A) or (1) for any of the above categories, please explain whether the situation is treatable or reversible, and if so, how: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (A) Intact/Exercises (B) Drives Car Or Uses Public Transportation (C) Independent Ambulation in Home Only; (D) Walker/Cane; (E) Requires Assistance If you circled (C), (D), or (E), is situation treatable or reversible? If so, how? _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (A) No Assistance Needed; (B) Requires Assistance with (1) Meals (2) Bathing (3) Dressing (4) Toileting/Feeding If you circled any of (B), is individual aware that assistance is required? _________________________________________ Is individual willing to accept assistance? _________________________________________ Is individual able to arrange for assistance? _________________________________________ (A) No Active Problem; (B) Initiates Problem Identification; (C) Actively Cooperative; (D) Passively Cooperative; (E) Passively Uncooperative; (F) Actively Uncooperative (CIRCLE ONE IN (A) AND ONE IN (B)) (A) SUPPORT: (1) Very Good Supportive Network; (2) Some Support From Family And Friends; (3) No Or Limited Support From Family/Friends; (4) Needs Community Support; (5) Isolated/Homebound (B) SOCIAL SKILLS: (1) Very Good Social Skills; (2) Good Social Skills; (3) Interacts With Prompting; (4) Isolated I hereby certify that I have reviewed sections A, B, & C attached hereto and based on such assessments that the individual’s decision-making ability is as follows: (1) PLEASE DESCRIBE AS FULLY AS YOU CAN THE INDIVIDUAL’S DECISION-MAKING ABILITY IN EACH OF THE FOLLOWING AREAS: A. FINANCIAL MATTERS _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ B. HEALTH CARE MATTERS _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ C. RELATIONSHIPS _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ D. RESIDENTIAL MATTERS _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (2) PLEASE INDICATE YOUR OPINION REGARDING WHETHER THE INDIVIDUAL NEEDS A SUBSTITUTE DECISION-MAKER IN ANY OF THE FOLLOWING AREAS: (Circle one for each category. If you circle “limited” for any category, please explain.) (1) FINANCIAL MATTERS Yes No Limited _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (2) HEALTH CARE MATTERS Yes No Limited _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (3) RELATIONSHIPS Yes No Limited _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (4) RESIDENTIAL MATTERS Yes No Limited _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (5) OTHER: If there are any other areas in which you think the individual lacks decision-making ability or has limited decision-making ability, please explain. _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Names and titles of others who assisted in Preparation of This Assessment. _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ (1) The residence of the ward is _________________________________________ (2) The medical condition of the ward is: _________________________________________ _________________________________________ _________________________________________ (3) I perceive the following changes in the decision making capacity of the ward: _________________________________________ _________________________________________ _________________________________________ (4) The following is a summary of the actions I have taken and decisions I have made on behalf of the ward during the last year: _________________________________________ _________________________________________ _________________________________________ (If more space is needed, please attach a supplement). _________________________________________ Guardian _________________________________________ Date STATE OF RHODE ISLAND PROBATE COURT OF COUNTY OF THE _________________________________________ (Estate Name) _______ Probate Court No. ___________ Now comes (Name of Guardian Ad Litem) for (Name of Proposed Ward) and reports that on (Date), I personally visited the proposed ward at (Address). I explained to (Name of Proposed Ward) the following: * The nature, purpose, and legal effect of the appointment of a guardian; * The hearing procedure, including, but not limited to, the right to contest the petition, to request limits on the guardian’s powers, to object to a particular person being appointed guardian, to be present at the hearing, and to be represented by legal counsel; * The name of the person known to be seeking appointment as guardian: Based on such visit and the respondent’s reaction thereto, I make the following determination regarding the respondent’s desire to be present at the hearing, to contest the petition, to have limits placed on the guardian’s powers and respondent’s objection, if any, to a particular person being appointed as guardian. _________________________________________ _________________________________________ _________________________________________ _________________________________________ Based on my review of the petition, the decision making assessment tool, my interview with the prospective guardian, my visit with the respondent, and interviews and discussions with other parties, I made the following additional determinations: Regarding whether the respondent is in need of a guardian of the type prayed for in the petition: _________________________________________ _________________________________________ _________________________________________ _________________________________________ Regarding whether the guardian ad litem has, in the course of fulfilling his or her duties, discovered information concerning the suitability of the individual or entity to serve as such guardian: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________
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