Annual Guardianship Plan

Page 1 of 12 Annual Guardianship Plan (Pursuant to F.S. 744.367, the Report with Original Signatures is due within 90 days after the last day of the anniversary month that the letters of guardianship were signed.) In the Circuit Court, Sixth Judicial Circuit, Florida County: Select County I N R E : G UARDIANSHIP OF : Social Security Number: Case Number: For the period: through Guardianship Inception Date: Guardian Name : Attorney Name : This Report, with original signatures, is due within 90 days after the last day of the anniversary month that the letters of guardianship were signed. The Ward is living: In a private residence leased or owned by them (house, condo, apartment). In a private residence not leased or owned by them (such as family member). In a facility (Skilled Nursing, Assisted Living, etc) Address and Phone Number where Ward is currently residing: Address: City, State, ZIP: Phone: Mailing Address for Ward (if different from above): Mailing Address: City, State, ZIP: The guardian(s) submit(s) and propose(s) the following plan. Filed separately is the Annual Physician222s Report. Together, these are the Annual Report of the Guardians(s) of the Person. Annual Medical Report: A report of a physician who examined the Ward no more than 90 days before the beginning of the applicable reporting period is to be filed separately, but at the same time as this plan. The report must contain an evaluation of the Ward222s condition and a statement of the current level of capacity of the Ward. Note 1: The rights on the physician222s report should match the Order Determining Incapacity and/or Order Appointing Guardian (signed when Letters were issued) or the guardian must either file a petition to remove or restore rights as appropriate, or provide an explanation for why no change should be made. For Official Use Only: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 2 of 12 Note 2: Per Administrative Order 2009-036, you must file an updated Disaster Plan when you file the annual plan if the ward has changed residence or a new guardian has been appointed. 1. The places the ward has lived (resided) during the prior 12 months Facility222s name or owner of the private residence222s name (first line) Street Address (second line) City, State and Zip Code (third line) Phone Number (fourth line) Type of Facility Approximat e Dates Of Residence 1 From To 2 From To 3 From To 4 From To 5 From To 6 From To 7 From To 8 From To 9 From To 10 From To American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 3 of 12 2. If the ward222s address has changed since the last plan filed (check all that apply): N/A, the ward has not moved since the last plan was filed. The move was within this county and a change of address was provided to the court. The move was within this Circuit (Pinellas to Pasco or Pasco to Pinellas) and Notice was provided to the court within 15 days of the move. The notice stated the compelling reasons for, and expected duration of, the move. The move was not within this Circuit (Pasco/Pinellas) and prior court approval was obtained. The move was not within this Circuit (Pasco/Pinellas) and a petition to change venue is or has been filed wit h this plan. plan. 3. For the best welfare of the ward in a setting best suited for his/her needs, the undersigned guardian plans as follows: A The guardian states the place and kind of residential setting best suited for the needs of the ward is: Assisted Living (ALF) Group Home Intermediate Private Residence Skilled Nursing Specialized State Hospital Other (Please Explain Below) . Explanation: B. The guardian will ensure that the above is the best residential setting for the Ward by: Periodically Assessing Needs The Ward retains the right to decide No change, unless required by medical condition C. Provision for medical care services for the ward: (Check all applicable boxes and provide explanation below) Routine examination by primary care physician Routine examination by dentist Routine examination by Ophthalmologist Routine examination by Specialist 226 area of specialty Physical Therapy Speech Therapy Occupational Therapy The ward retains the right to make their own decision None (Please Explain Below) Other (Please Explain Below) Explanation: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 4 of 12 D. Provision for mental health services for the ward: (Check all applicable boxes and provide explanation below) Routine examination by Psychiatrist/Psychologist Ward retains the right to make own decisions Ongoing Treatment Outpatient Ongoing Treatment Inpatient None (Please Explain Below) Other (Please Explain Below) Explanation: E. Provision for the personal care of the ward, such as bathing, grooming and feeding: (Check all applicable boxes and provide explanation below) Care Facility Nurses and Aides Family and Friends Ward does without assistance None; ward can provide own personal care Other(Please Explain Below) Explanation: F. Provision for socialization and/or recreational activities for the ward: (Check all applicable boxes and provide explanation below) Care Facility Nurses and Aides Family and Friends The ward retains the right to make their own decision None (Please Explain Below) Other (Please Explain Below) Explanation: G. Description of health and accident insurance and any other private or governmental benefits to which the Ward is receiving to meet any part of the costs of medical, mental health or related services provided to the Ward. (Check all applicable boxes and pr ovide explanation below) Eligible Applied For Social Security Social Security Disability Income (SSDI) Health Maintenance Organization (HMO) American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 5 of 12 Supplemental Security Income (SSI) Optional State Supplement Institutional Care Program Supplemental Insurance (Continued Next Page) Pension Medicare Medicaid VA Trusts None (Please Explain Below) Other (Please E xplain Below) Explanation: 4 . Professional Medical Treatment performed on the Ward during the prior 12 months Data Entry Format: 1st Line input: Provider222s first name, last name, and middle initial 2nd Line input: Street Address 3rd Line input: City, State and Zip Code 4 th Line input : Phone Number Type of Provider Number of Visits 1 2 3 4 5 6 7 American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 6 of 12 8 9 10 5 . Social Skills, Abilities and Activities of the Ward A. Describe the social skills (abilities) of the Ward (i.e.: the Ward can communicate well; the Ward communicates with gestures; the Ward cannot communicate at all; etc205). In addition, please describe any changes from the previous plan period. Explanation: B. Describe the activities undertaken in an effort to increase the capacity of the Ward in the prior plan period (i.e.: encouragement; physical or mental therapy, rehabilitative services; etc205) In addition, please explain whether or not these activities were effective. Explanation: 6. Is the Ward now capable of having some or all of the following rights restored? Place a checkmark where applicable Yes No Not Removed Need s to be Restored A. Right to marry: B. Right to Vote: C. Right to personally apply for government benefits: D. Right to have a driver222s license: E. Right to travel: F. Right to seek or retain employment: G. Right to contract: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 7 of 12 H.Right to sue and be sued I. Right to manage property or to make any gift of disposition: J.Right to determine residence: K.Right to consent to medical treatment: L. Right to make decisions about social environment or other aspects of social life: 7.If you answered 223Yes224 to any right in question 5, and the doctor has indicated on thephysician222s report that a right may be restored, you must file a petition to restore the right. Ifyou do not agree with the physician222s report, please provide an explanation. Explanation: 8 .Rate the following Activities of Daily Living (ADL222s) A.Eating B.Prepare Meals: C.Heavy Chores (e.g., vacuuming) D.Light Hou