2017 Rhode Island General Laws
Title 33 - Probate practice and procedure
Chapter 33-15 - Limited Guardianship and Guardianship of Adults
Section 33-15-47 - Forms.
§ 33-15-47. Forms.
The following forms shall be used for the purposes of this chapter:
STATE OF RHODE ISLAND PROBATE COURT OF THE
COUNTY OF ..............
No.
ESTATE OF ............................
PERSONAL ESTATE ESTIMATED AT $........ CITY/TOWN OF
19
hereby petitions the Probate Court of the
Petitioner
city/town of ................ to appoint a limited guardian/guardian for ................ who currently resides at
Address
...................., in the city/town of ........................................, and whose date of birth is .....................
Based upon an assessment conducted by
.................... on, which
Date
functional assessment reflects the current level of functioning of ...................., it has been determined that
Respondent Respondent
lacks decision-making ability in one or more of the following areas as indicated:
.... health care
.... financial matters
.... residence
.... association
.... other
Regarding each area indicated, please describe the specific assistance needed:
Indicate which of the following less restrictive alternatives to guardianship have been explored and deemed inappropriate as indicated:
.... Durable Power of Attorney for Health Care
.... Living Will
.... Power of Attorney
.... Durable Power of Attorney
.... Trusts
.... Joint Property Arrangements
.... Representative Payee
.... Money Management
.... Single Court Transactions
.... Government Benefit and Social Service Programs
.... Housing Options
.... Other
Please describe the basis for the determination that the alternative will not meet the needs of the respondent for each alternative explored and deemed inappropriate:
The following individual/agency is willing to serve as guardian:
Upon information and belief the above individual/agency has:
Î No conflict of interest that would interfere with guardianship duties.
Î No criminal background that would interfere with guardianship duties.
Î The capacity to manage financial resources involved.
Î The ability to meet requirements of law and unique needs of individual.
Î Demonstrated willingness to undergo training.
The Respondent has the following heirs at law:
NAME: RESIDENCE:
Signature
Name
Address
Telephone
Subscribed and sworn to before me as to the truth of the above facts by ........ in ................ on the ........................ day of ................................, 19.....................................
Notary Public
Print Name
.................... ........................................
Dated PROBATE JUDGE
This notice should be served at once and returned to the clerk of the court.
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
BY THE PROBATE COURT OF THE ............ OF ........................
BY THE COUNTY OF ................ AND STATE AFORESAID
To ........................
Estate or ................
Docket No. ..............
A petition for Limited Guardianship/Guardianship has been filed in the Probate Court of the city/town of.
has requested that the Probate Court appoint
Petitioner
a limited guardian/guardian for you.
A hearing regarding this Petition shall be held
On: ....................................
date
At: ....................................
time
at the Probate Court for the town of.
Address
The Petition requests that the Probate Court consider the qualification of the following individual/agency to serve as your limited guardian/guardian:
A guardian ad litem will be appointed by the Probate Court to visit you, explain the process and inform you of your rights.
You have the right to attend the hearing to contest the petition, to request that the powers of the guardian be limited or to object to the appointment of particular individual/agency limited guardian/ guardian. If you wish to contest the petition, you have the right to be represented by an attorney, at state expense, if you are indigent.
If the Petition is granted and a limited guardian/guardian is appointed, the Probate Court may give the limited guardian/guardian the power to make decisions about one or more of the following:
Your health care; your money; where you live; and with whom you associate.
Copies of this Notice will be mailed to:
The administrator of any care or treatment facility where you live or receive primary services; your spouse, and heirs at law; any individual or entity known to petitioner to be regularly supplying protection services to you.
I certify that I hand-delivered and read this Notice to .................... on the ........ day of ................, 19.....................
Signature
Print Name
Address
I certify that, as required by Rhode Island General Laws § 33-15-17.1(e), I mailed a copy of this Notice to the following persons, at the addresses listed, on the ........ day of ................, 19.....................
Signature
Print Name
Address
Subscribed and sworn to before me this ........ day of ................, 19.....
Notary Public
Judge of the Probate Court of the ........ of ................ this ........................ day of ........, 19.............
Clerk
Name of Individual being assessed: Current Address:
.................... ......................................................
..................................
Date of Birth: Permanent Address (if different):
.................... ......................................................
..................................
This document will be used by a Probate Court to determine whether to appoint a guardian to assist this individual in some or all areas of decision-making.
This document has two parts. Please first complete the part which is right after these instructions, titled Assessment. Then complete the second section, titled Summary.
To a physician completing this document: The individual's treating physician must complete this document. If there is any information of which the treating physician completing this document does not have direct knowledge, he or she is encouraged to make such inquiries of such other persons as are necessary to complete the entire form. Those persons might include other medical personnel such as nurses, or other persons such as family members or social service professionals who are acquainted with the individual. If the physician has received information from others in completing the form, the names of those individuals must be listed on the Summary.
To a non-physician completing this document: Professionals or other persons acquainted with the individual being assessed may also complete this document. If there is information of which a non-physician completing this document does not have knowledge, such non-physician may either leave portions of the document blank, or also make inquiries or do such investigation as is necessary to complete the entire document. Again, the names of any individual from whom information is derived should be listed on the Summary.
The document must be signed and dated by the person completing it. It does not need to be notarized.
THE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON
....................
(DATE)
1. DIAGNOSIS and PROGNOSIS:
2. MEDICATION (PLEASE LIST):
How do the above medications, if any, affect the individual's decision-making ability? Please explain:
3. CURRENT NUTRITIONAL STATUS:
(A) Intact; (B) Mild Impairment; (C) Moderate Impairment; (D) Severe Impairment
(A) Intact; (B) Mild Impairment; (C) Shifting/Wandering; (D) Delirium; (E) Unresponsive
(A) Intact; (B) Able to Make Most Decisions; (C) Impaired; (D) Gross Impairment
(A) Intact (B) Sensory Deficits (Hearing/Speech/Sight)
(C) Impairment In Comprehension/Speech: Mild/Moderate/Severe
(D) Completely Unresponsive
(A) ANXIETY/DEPRESSION: (1) None (2) History of Anxiety/Depression
(3) Moderate Symptoms of Anxiety/Depression
(4) Severe symptoms with sleep/appetite/energy disturbance
(5) Suicide/Homicidal
(B) OTHER: (1) Suspiciousness/Belligerence/Explosiveness
(2) Delusions/Hallucinations (3) Unresponsive
If you circled any of the above, other than (A) or (1) for any of the above categories, please explain whether the situation is treatable or reversible, and if so, how:
(A) Intact/Exercises (B) Drives Car Or Uses Public Transportation
(C) Independent Ambulation in Home Only; (D) Walker/Cane; (E) Requires Assistance
If you circled (C), (D), or (E), is situation treatable or reversible? If so, how?
(A) No Assistance Needed;
(B) Requires Assistance with (1) Meals (2) Bathing (3) Dressing (4) Toileting/Feeding
If you circled any of (B), is individual aware that assistance is required?
Is individual willing to accept assistance?
Is individual able to arrange for assistance?
(A) No Active Problem; (B) Initiates Problem Identification; (C) Actively Cooperative; (D) Passively Cooperative; (E) Passively Uncooperative; (F) Actively Uncooperative
SUPPORT:
(1) Very Good Supportive Network; (2) Some Support From Family And Friends; (3) No Or Limited Support From Family/Friends; (4) Needs Community Support; (5) Isolated/Homebound
(B) SOCIAL SKILLS:
(1) Very Good Social Skills; (2) Good Social Skills; (3) Interacts With Prompting; (4) Isolated
I hereby certify that I have reviewed sections A, B, & C attached hereto and based on such assessments that the individual's decision-making ability is as follows:
(1) PLEASE DESCRIBE AS FULLY AS YOU CAN THE INDIVIDUAL'S DECISION-MAKING ABILITY IN EACH OF THE FOLLOWING AREAS:
A. FINANCIAL MATTERS
B. HEALTH CARE MATTERS
C. RELATIONSHIPS
D. RESIDENTIAL MATTERS
(2) PLEASE INDICATE YOUR OPINION REGARDING WHETHER THE INDIVIDUAL NEEDS A SUBSTITUTE DECISION-MAKER IN ANY OF THE FOLLOWING AREAS: (Circle one for each category. If you circle "limited" for any category, please explain.)
(1) FINANCIAL MATTERS Yes No Limited
(2) HEALTH CARE MATTERS Yes No Limited
(3) RELATIONSHIPS Yes No Limited
(4) RESIDENTIAL MATTERS Yes No Limited
(5) OTHER: If there are any other areas in which you think the individual lacks decision-making ability or has limited decision-making ability, please explain.
....................
Signature
Name (Print or Type)
Title
Date
Names and titles of others who assisted in Preparation of This Assessment.
STATE OF RHODE ISLAND PROBATE COURT OF THE
COUNTY OF ............
Estate of ........................ Docket No.
(1) The residence of the ward is
(2) The medical condition of the ward is:
(3) I perceive the following changes in the decision making capacity of the ward:
(4) The following is a summary of the actions I have taken and decisions I have made on behalf of the ward during the last year:
(If more space is needed, please attach a supplement).
Guardian
Date
STATE OF RHODE ISLAND PROBATE COURT OF
COUNTY OF .............. THE
(Estate Name)
Probate Court No. ......
Now comes (Name of Guardian Ad Litem) for (Name of Proposed Ward) and reports that on (Date), I personally visited the proposed ward at (Address). I explained to (Name of Proposed Ward) the following:
* The nature, purpose, and legal effect of the appointment of a guardian;
* The hearing procedure, including, but not limited to, the right to contest the petition, to request limits on the guardian's powers, to object to a particular person being appointed guardian, to be present at the hearing, and to be represented by legal counsel;
* The name of the person known to be seeking appointment as guardian:
Based on such visit and the respondent's reaction thereto, I make the following determination regarding the respondent's desire to be present at the hearing, to contest the petition, to have limits placed on the guardian's powers and respondent's objection, if any, to a particular person being appointed as guardian.
Based on my review of the petition, the decision making assessment tool, my interview with the prospective guardian, my visit with the respondent, and interviews and discussions with other parties, I made the following additional determinations:
Regarding whether the respondent is in need of a guardian of the type prayed for in the petition:
Regarding whether the guardian ad litem has, in the course of fulfilling his or her duties, discovered information concerning the suitability of the individual or entity to serve as such guardian:
Respectfully submitted,
Date: ........................
(Name of Guardian Ad Litem)
History of Section.
(P.L. 1992, ch. 493, § 4; P.L. 1994, ch. 359, § 1; P.L. 1996, ch. 110, § 9.)
