Activities Of Daily Living

Cal. Form L-3016

California Superior Local Rules

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org L-3016 ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO.: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: E-MAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE Costa Mesa Justice Complex 3390 Harbor Blvd.

Costa Mesa, CA 92626-1554 CONSERVATORSHIP OF (Name): CASE NUMBER: ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE TO PETITIONER: The purpose of this form is to provide information from the Petitioner(s), the proposed conservatee, the proposed conservatee’s counsel, and/or the proposed conservatee’s primary care physician. A. For Individuals with Cognitive Impairment B. For Individuals with Intellectual Disabilities C. For Individuals with Acquired Brain Injuries D. For Individuals with Psychiatric Disorders This form is to be completed in all general conservatorship matters.

If no capacity declaration is required, this form is to be completed by a psychiatrist/psychologist/primary care physician. If a capacity declaration is required, this form is to be completed by petitioner, petitioner’s counsel, proposed conservatee’s counsel, or if advised by counsel, the proposed conservatee themselves. A relative, non- relative, or friend may also complete the form. Nothing prevents more than one person from completing and filing local form L-3016. GENERAL INFORMATION: 1. Name of person completing form: 2. Address and phone number of the person completing form: 3.

Relationship to Proposed Conservatee: a. I am a ☐ Relative ☐ Non-Relative/Friend ☐ Petitioner ☐ Petitioner’s Counsel ☐ Proposed Conservatee ☐ Proposed Conservatee’s Counsel ☐ Proposed Conservatee’s Psychiatrist, Psychologist, or Primary Care Physician. I last saw the Proposed Conservatee on (date):4.

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org EVALUATION OF PROPOSED CONSERVATEE’S DAILY FUNCTION ABILITY: Proposed Conservatee’s Level of Education: Language(

s) Spoken: CLIENT DESCRIPTION (including their concerns, abuse information, and current services in place) and CLIENT APPEARANCE: CAREER HISTORY: . HEALTH STATUS and PROVIDERS: .

Functioning Levels (Activities of Daily Living/ADL) Bathing: either sponge, shower, or tub ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Dressing: includes choosing and obtaining clothing ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Toileting: going to toilet, cleaning self, and changing clothes ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments:

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org Transfer: can get in and out of bed; can get on and off chair ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Continence: both urine and bowel function completely by self ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Feeding: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Any other information regarding this evaluation of the client’s “Activities of Daily Living” function: Instrumental Activities of Daily Living (IADL) Ability to use Telephone/Cellular Phone: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Shopping: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments:

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org Food Preparation: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Housekeeping: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Laundry: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Mode of Transportation: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Responsible for Medications: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Any other information regarding this evaluation of the client’s “Activities of Daily Living” function:

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org Managing Finances Ability to handle finances: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Ability to appreciate the value of money: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Can manage small amounts of cash for purchases: (Less than $20) – (Understanding cost of items and change needed) ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Can manage large amounts of cash for purchases: (More than $20) – (Understanding cost of items and change needed) ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Can understand how to make online purchases with a credit card: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments:

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org Can understand how to use a debit card/credit card responsibly: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Can resist others who may take advantage of client’s money: (Cash, debit, or credit card) ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Can keep track of charitable donations and resist requests if they exceed reasonable donation allowance given client’s income: ☐ No impairment ☐ Impairment present ☐ So impaired as to be incapable of being assessed ☐ Not assessed Comments: Any other information regarding this evaluation of the client’s financial management function/skills: Please note activities which are important for client’s quality and enjoyment of life and assistance needed to maintain these activities: Safety Observations: Social Network/Circle of Support:

Approved for Mandatory Use Orange County Superior Court L-3016 (Rev Oct 13, 2022) ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT OF THE PROPOSED CONSERVATEE OCSC rule 611.03 www.occourts.org Suspected type(

s) of abuse client is dealing with: ☐ Physical abuse ☐ Financial abuse ☐ Self- Neglect ☐ Abandonment ☐ Emotional abuse ☐ Sexual abuse ☐ Unable to assess Comments: Client possibly at risk for: ☐ Physical abuse ☐ Financial abuse ☐ Self- Neglect ☐ Abandonment ☐ Emotional abuse ☐ Sexual abuse ☐ Other Comments: Services client may benefit from: ☐ Housing resources ☐ House- keeping resources ☐ Financial resources ☐ Transportation resources ☐ Mental health resources ☐ Legal services ☐ Monitoring resources (e.g., friendly visitor) Comments: Other services not mentioned above: Case Management Need: Additional relevant information: (any information not included in any of the areas above).

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date ______________________________________ Type or Print Name Signature of Declarant This form was supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $494,048 with 75% funded by ACL/HHS and $0 amount and 25% (pro bono, UCI Division of Geriatrics) funded by non- government source(s). The contents are those of the author(

s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government. The form has been shared for court use.

Document details

Collection	California Superior Local Rules
Citation	Cal. Form L-3016
Type	court_rule
Language	en
Format	pdf
Source	CA_LOCAL
Identifier	6530f7721d1f87fbcff1adfb7ad2238dd4e1ed0c

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