Conservatorship Questionnaire - Law Offices of Rozsa Gyene

SECTION 1: PETITIONER INFORMATION

This is the person requesting to be appointed as conservator.

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Relationship to Proposed Conservatee *

Are you requesting to be appointed as: *

Conservator of the Person

Conservator of the Estate

SECTION 2: PROPOSED CONSERVATEE INFORMATION

This is the person who needs a conservator.

First Name *

Middle Name

Last Name *

Date of Birth *

Current Age *

Current Address *

City *

State *

ZIP Code *

Phone Number (if available)

Current Living Situation

Type of Residence *

Is the proposed conservatee able to attend the court hearing?

Yes

No (medical documentation required)

SECTION 3: REASONS FOR CONSERVATORSHIP

This section requires specific details about why conservatorship is necessary.

Primary reason(s) for conservatorship (check all that apply): *

Dementia/Alzheimer's Disease

Mental Illness

Developmental Disability

Brain Injury

Chronic Substance Abuse

Physical Disability

Other

Medical Diagnosis/Conditions (be specific): *

What is the conservatee unable to provide for? *

Describe any danger to self or others:

SECTION 4: ALTERNATIVES TO CONSERVATORSHIP

California law requires consideration of less restrictive alternatives before conservatorship.

Have any of these alternatives been tried or considered?

Power of Attorney

Trust

Supported Decision Making

Representative Payee

None

Explain why alternatives are not workable: *

SECTION 5: MEDICAL INFORMATION

Primary Physician

Doctor's Name *

Doctor's Phone *

Doctor's Address

Has a Capacity Declaration (GC-335) been completed?

Yes

No (will be required)

In Process

Medications

List all current medications:

Does the conservatee have dementia?

Yes

No

SECTION 6: RELATIVES TO BE NOTIFIED

California law requires notice to all relatives within the second degree (spouse, children, parents, siblings, grandparents, grandchildren).

SECTION 7: ESTATE INFORMATION

Complete this section if requesting Conservatorship of the Estate.

Assets

Real Property (Real Estate)

Yes

No

Bank Accounts

Other Assets

Estimated value of personal property (furniture, jewelry, etc.):

Vehicles (make, model, year, value):

Stocks, bonds, investments:

Income

Monthly Income Sources:

Social Security

Pension

VA Benefits

Disability

Rental Income

Other

Total Estimated Monthly Income:

Debts and Expenses

Estimated Monthly Expenses:

List any debts (mortgages, credit cards, loans):

SECTION 8: BOND REQUIREMENT

A bond is typically required for conservators of the estate unless waived by the court.

Estimated value of estate requiring bond:

Are you requesting bond waiver?

Yes

No

SECTION 9: PROPOSED DUTIES AND POWERS

Powers of Conservator of the Person

Which powers are you requesting? (check all that apply):

Fix residence or dwelling

Give medical consent

Enter into contracts

Make education decisions

Control social and sexual contacts

Make decisions about marriage

Powers of Conservator of the Estate

Which powers are you requesting? (check all that apply):

Collect income and assets

Pay bills and expenses

Make investments

Sell property

Borrow money

Make gifts (requires special court approval)

SECTION 10: ADDITIONAL INFORMATION

Is this a temporary or permanent conservatorship request?

Permanent

Temporary (emergency)

Is this a limited conservatorship (for developmentally disabled adults)?

Yes

No

Preferred Court County:

Are there any urgent circumstances requiring immediate action?

Additional Information or Special Circumstances: