Declaration Physician Or Qualified Liscensed Psychologist Exhibit A

Cal. Form L9-84B

California Superior Local Rules

Approved for Optional Use L-0984b (Rev. March, 2014) DECLARATION PHYSICIAN OR QUALIFIED LISCENSED PSYCHOLOGIST EXHIBIT A www.occourts.org DECLARATION OF PHYSICIAN OR QUALIFIED LICENSED PSYCHOLOGIST CONSERVATORSHIP RE-EVALUATION Name: Case No.: ________________________________________ Address: City, State, Zip: Age: Sex: Birthdate: Date of Current Evaluation: Previous Diagnosis: INSTRUCTIONS FOR EVALUATION Please complete the following three areas of interest to assist us in making a decision as to whether the above-named person should continue to have a conservator. 1. Is there a mental disorder?

Please give a diagnosis and explain the symptoms. 2. Can the individual provide for his or her basic needs (i.e., food, clothing, or shelter) in an unsupervised setting? Why do you feel he or she can or cannot? 3. Do you feel this individual is incapable or unwilling to accept voluntary treatment? I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (date): (SIGNATURE OF EVALUATOR) (SIGNATURE OF EVALUATOR) (TITLE) (TITLE)

Document details

Collection	California Superior Local Rules
Citation	Cal. Form L9-84B
Type	court_rule
Language	en
Format	pdf
Source	CA_LOCAL
Identifier	2c238b125ced96954ca90a2fbdac8a16facf7d61

Source file is stored in the law ingest library (pdf).