GC-335 Capacity Declaration - Conservatorship
Most of this form is to be filled out by the medical professional. This form can be filled out by the medical professional before and filed with the initial GC-310 “Petition for Appointment of Probate Conservator” or can be filed at a later date but before the court hearing for the conservatorship.
An important thing is that once you receive this document back from the medical professional be sure to review it for completeness. Make sure it is signed on page 1 and 3, and initial on page 3 if applicable. The printing and signing of the name on two pages can be overlooked. The place that needs to be initialed on page 3 is often overlooked.
Form Links
Filled in Example GC-335 Form- You can edit it to your situation print, and file it at your local California Superior Court. The form is the same as the one you can get from a California Superior Court Website.
Blank GC-335 Form
http://www.courts.ca.gov/forms.htm?filter=GC California Probate Conservatorship Complete List Downloadable
Content
The each page notes are below the respective image of the form page.GC-335 Page 1 Notes
GC-335 Page 2 Notes
GC-335 Page 3 Notes
GC-335 Form in HTML so it can be Translated
Page 1 Notes:
To Physician, Psychologist, or Religious Healing Practitioner BoxYou need to fill out this box checking “A” and “B” along with the date of the hearing.
General Information
You can fill out the doctor’s name, address and telephone number or leave it to be filled out by the doctor.
The rest of this page is to be filled out, print name and signed by the medical professional.
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Page 2 Notes:
Except for the header, page 2 is to be filled out by the medical professional.Top
Page 3 Notes:
Except for the header, page 3 is to be filled out, print name and signed by the medical professional.Note the “Ability To Consent To Medical Treatment” if “7 b.” is checked, the medical professional must initial at “(Declarant must initial here if item 7b applies________)".
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GC-335 Form in HTML so it can be Translated
The GC-335 form is reproduced here in html so that it can easily be translated into multiple languages. You can not use this form to submit to court in any language. You have to use the GC-335 pdf form and English.GC-335
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar
number, and address):
NAME: John Doe & Jane Doe
FIRM NAME:
STREET ADDRESS: 1234 ABC Street
CITY: San Francisco STATE: CA ZIP CODE: 94102
TELEPHONE NO.: 415-123-4567 FAX NO.:
E-MAIL ADDRESS: info@raisingautism.net
ATTORNEY FOR (name): Petitioners, In Pro Per
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
San Francisco
STREET ADDRESS: 400 MCALLISTER STREET
MAILING ADDRESS: 400 MCALLISTER STREET
CITY AND ZIP CODE: SAN FRANCISCO, CA 94102
BRANCH NAME: PROBATE CONSERVATORSHIP OF THE
PERSON 
ESTATE OF (Name): Terry Morgan Doe
number, and address):
NAME: John Doe & Jane Doe
FIRM NAME:
STREET ADDRESS: 1234 ABC Street
CITY: San Francisco STATE: CA ZIP CODE: 94102
TELEPHONE NO.: 415-123-4567 FAX NO.:
E-MAIL ADDRESS: info@raisingautism.net
ATTORNEY FOR (name): Petitioners, In Pro Per
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
San Francisco
STREET ADDRESS: 400 MCALLISTER STREET
MAILING ADDRESS: 400 MCALLISTER STREET
CITY AND ZIP CODE: SAN FRANCISCO, CA 94102
BRANCH NAME: PROBATE CONSERVATORSHIP OF THE
PERSON ESTATE OF (Name): Terry Morgan Doe
CONSERVATEE PROPOSED CONSERVATEE
FOR COURT USE ONLY
CASE NUMBER:
PCN-16-123456
PCN-16-123456
TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER
The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply):A.
is able to attend a court hearing to determine whether a conservator should be appointed to care for him orher. The court hearing is set for (date): March 7, 2016 . (Complete item 5, sign, and file page 1 of this
form.)
B.
has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3,and file pages 1 through 3 of this form.)
C.
has dementia and, if so, (1) whether he or she needs to be placed in a secured-perimeter residential carefacility for the elderly, and (2) whether he or she needs or would benefit from dementia medications.
(Complete items 6 and 8 of this form and form GC-335A; sign and attach form GC-335A. File pages 1
through 3 of this form and form GC-335A.)
(If more than one item is checked above, sign the last applicable page of this form or form GC-335A if item C is checked. File page 1 through the last applicable page of this form; also file form GC-335A if item C is checked.)
COMPLETE ITEMS 1–4 OF THIS FORM IN ALL CASES.
1. Name): Doctors Name
2. (Office address and telephone number): Doctors address and telephone number
3. I am
a.
a California licensed physician psychologist acting within the scope of my licensure with at least two years' experience in diagnosing dementia.b.
an accredited practitioner of a religion whose tenets and practices call for reliance on prayer alone for healing,which religion is adhered to by the (proposed) conservatee. The (proposed) conservatee is under my
treatment. (Religious practitioner may make the determination under item 5 ONLY.)
4. (Proposed) conservatee (name):
a. I last saw the (proposed) conservatee on (date):
b. The (proposed) conservatee
is is NOT a patient under my continuing treatment.ABILITY TO ATTEND COURT HEARING
5. A court hearing on the petition for appointment of a conservator is set for the date indicated in item A above.
(Complete a or b.)
a.
The proposed conservatee is able to attend the court hearing.b.
Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all itemsbelow that apply)
(1)
on the date set (see date in box in item A above).(2)
for the foreseeable future.(3)
until (date):(4) Supporting facts (State facts in the space below or check this box
and state the facts in Attachment 5):I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
 |
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| (TYPE OR PRINT NAME) | (SIGNATURE OF DECLARANT) |
Page 1 of
Form Adopted for Mandatory Use
Judicial Council of California
GC-335 [Rev. January 1, 2004]
Judicial Council of California
GC-335 [Rev. January 1, 2004]
CAPACITY DECLARATION -- CONSERVATORSHIP
Probate Code, § 811,
813, 1801, 1825
1881, 1910, 2356.5
813, 1801, 1825
1881, 1910, 2356.5
GC-335
GUARDIANSHIP CONSERVATORSHIP OF THE Person EstateOF (name): Terry Morgan Doe
MINOR PROPOSED CONSERVATEE
CASE NUMBER:
PCN-16-1234566. EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTIONS
Note to practitioner: This form is not a rating scale. It is intended to assist you in recording your impressions of
the (proposed) conservatee's mental abilities. Where appropriate, you may refer to scores on standardized rating
instruments.
(Instructions for items 6A–6C): Check the appropriate designation as follows: a = no apparent impairment; b =
moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have
no opinion.)
A. Alertness and attention
(1) Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor)
a
be c d (2) Orientation (types of orientation impaired)
a
be c d Personad
be c Time (day, date, month, season, year)a
be c d Place (address, town, state)ad
be c Situation ("Why am I here?")(3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle)
a
be c d B. Information processing. Ability to:
(1) Remember (ability to remember a question before answering; to recall names, relatives, past presidents, and
events of the past 24 hours)
i. Short-term memory ad
be c ii Long-term memory a
be c d iii Immediate recall ad
be c (2) Understand and communicate either verbally or otherwise (deficits reflected by inability to comprehend
questions, follow instructions, use words correctly, or name objects; use of nonsense words)
ad
be c (3) Recognize familiar objects and persons (deficits reflected by inability to recognize familiar faces, objects, etc.)
a
be c d (4) Understand and appreciate quantities (deficits reflected by inability to perform simple calculations)
ad
be c (5) Reason using abstract concepts. (deficits reflected by inability to grasp abstract aspects of his or her situation
or to interpret idiomatic expressions or proverbs)
a
be c d (6) Plan, organize, and carry out actions (assuming physical ability) in one's own rational self-interest (deficits
reflected by inability to break complex tasks down into simple steps and carry them out)
ad
be c (7) Reason logically.
a
be c d C. Thought disorders
(1) Severely disorganized thinking (rambling thoughts; nonsensical, incoherent, or nonlinear thinking)
ad
be c (2) Hallucinations (auditory, visual, olfactory)
ad
be c (3) Delusions (demonstrably false belief maintained without or against reason or evidence)
ad
be c (4) Uncontrollable or intrusive thoughts (unwanted compulsive thoughts, compulsive behavior).
a
be c d (Continued on next page)
GC-335 [Rev. January 1, 2004]
CAPACITY DECLARATION -- CONSERVATORSHIP
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GC-335
GUARDIANSHIP CONSERVATORSHIP OF THE Person EstateOF (name): Terry Morgan Doe
MINOR PROPOSED CONSERVATEE
CASE NUMBER:
PCN-16-1234566. (continued)
D. Ability to modulate mood and affect. The (proposed) conservatee
has does NOT have a pervasiveand persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If
so, complete remainder of item 6D.)
I have no opinion.(Instructions for item 6D: Check the degree of impairment of each inappropriate mood state (if any) as
follows: a = mildly inappropriate; b = moderately inappropriate; c = severely inappropriate.)
Anger a
b c Euphoria a b c Helplessness a b c Anxiety a
b c Depression a b c Apathy a b c Fear a
b c Hopelessness a b c Indifference a b c Panic a
b c Despair a b c E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A–6D
(1)
do NOT vary substantially in frequency, severity, or duration.(2)
do vary substantially in frequency, severity, or duration (explain; continue on Attachment 6E if necessary):F.
(Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g.,diagnosis, symptomatology, and other impressions) is
stated below stated in Attachment 6F.ABILITY TO CONSENT TO MEDICAL TREATMENT
7. Based on the information above, it is my opinion that the (proposed) conservatee
a.
has the capacity to give informed consent to any form of medical treatment. This opinion is limited to medicalconsent capacity.
b.
lacks the capacity to give informed consent to any form of medical treatment because he or she is either (1)unable to respond knowingly and intelligently regarding medical treatment or (2) unable to participate in a
treatment decision by means of a rational thought process, or both. The deficits in the mental functions
described in item 6 above significantly impair the (proposed) conservatee's ability to understand and appreciate
the consequences of medical decisions. This opinion is limited to medical consent capacity.
(Declarant must initial here if item 7b applies: .)
8. Number of pages attached: 0I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
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| (TYPE OR PRINT NAME) | (SIGNATURE OF DECLARANT) |
GC-335 [Rev. January 1, 2004]
CAPACITY DECLARATION -- CONSERVATORSHIP
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