Annual Guardianship Plan

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT, IN AND FOR MIAMI-DADE COUNTY, FLORIDA, PROBATE DIVISION
ANNUAL GUARDIANSHIP PLAN
1. The Ward’s present location is:
2. Prior to the current residence, the Ward lived at the following location(s) during the past year:
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#
Facility Name, Address, and Phone Number
Type of Facility
Start Date of Residence
Approximate Ending Date of Residence
1
3. A. The guardian states the place and kind of residential setting best suited for the needs of the Ward is:
B. The guardian will ensure that the above is the best residential setting for the Ward by:
C. The guardian states that every facility where the Ward resided was licensed, if licensing is required by law:
4. Care plans were required to be prepared by any facility where the Ward resided during the preceding 12 months:
5. The guardian visited the Ward during the preceding 12 months as follows:
Note: Please select all that applies and enter the number of visits.
6. The following is a description of the medical and/or mental health treatment provided to the Ward during the preceding 12 months:
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#
Provider’s Name Address, and Phone Number
Type of Provider
Number of Visits
1
7. The guardian for the plan period proposes the following as to the provision of medical and rehabilitative services for the Ward:
8. The guardian for the plan period proposes the following as to the provision of mental health services for the Ward:
9. The Ward during the preceding 12 months was prescribed or took the following types of medications:
10. The guardian for the plan period proposes the following as to the provision of personal care services for the Ward:
11. The guardian for the plan period proposes the following as to the provision of social recreation for the Ward:
12. A. Baker Act - Was the Ward involuntarily placed or examined during the preceding 12 months under Chapter 394, F.S.?
B. How the Ward was involuntarily placed in a treatment facility?
13. The guardian provides the following statement as to the social condition of the Ward:
A. The guardian provides the following statement of the social skills of the Ward, including how well the Ward maintains interpersonal relationship with others:
B. The guardian provides the following description of the Ward’s activities at communication and visitation:
C. The guardian provides the following description of the unmet social needs of the Ward:
D. The guardian for the plan period proposes the following as to the provision of social services for the Ward:
14. The following activities were undertaken during the preceding 12 months in an effort to increase the capacity of the Ward:
15. The guardian during the preceding 12 months utilized the following health insurance, accident insurance, private benefits, or governmental benefits available to meet the costs of medical, mental health, or related services:
16. Can any of the following rights be restored?

Right To:

Answer

17. If you answered yes to any rights listed in question 16, or if the doctor has indicated on the attached physician’s report that a right may be restored - will restoration be sought?

Right To:

Answer

18. To assist the Court with review of the annual plan to determine if it is in the best interest of the Ward, please provide the following information: a. Please indicate the Ward’s ability to engage in activities of daily living or instrumental activities of daily living:

Right To:

Answer

B. The diagnosed mental disabilities of the Ward are:
C. The diagnosed physical disabilities of the ward are:
D. The assistive devices used by the Ward are:
E. The plan for the next twelve (12) months for disaster preparedness for the Ward is:
19. The following is a list of all preexisting orders not to resuscitate executed under §401.45(3), Fla. Stat or preexisting advance directives as defined in §765.101, Fla. Stat., concerning the adult ward, discovered during the preceding 12 months.
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Orders Not to Resuscitate or Advance Directives

#
Title of Order/Directive
Date of Order/Directive
Suspended by Court (Yes/No)
Steps Taken to Identify and Locate Order/Directive
1
20. The following is a listing of the types, sources and total amounts of all remuneration (i.e., payments or other benefits made directly or indirectly, overtly or covertly, or in cash or in kind) received by the guardian for services rendered to or on behalf of the ward.
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Remuneration

#
Date of Court Order if any
Type of Remuneration
Source
Amount
1
Total Amount
CERTIFICATION AND SIGNATURE OF GUARDIAN(S)

(Check all that apply)

UNDER PENALTIES OF PERJURY, I declare that I have read and examined the foregoing plan, and the facts alleged are true, to the best of my knowledge and belief.

Guardian

Co-Guardian
CERTIFICATION AND SIGNATURE OF PREPARER

The preparation of this form is based upon the information provided by the guardian(s) and/or attorney with no independent verification of the information contained herein. I have not audited or reviewed the guardianship plan or documents supporting the preparation of the guardianship plan and, accordingly, do not express an opinion or any other form of assurance as to the accuracy of the information contained in the plan.

CERTIFICATION AND SIGNATURE OF GUARDIAN’S ATTORNEY

The undersigned hereby notifies the Court of the filing of the initial guardianship plan of the guardian of the person. This initial plan is the representation of the guardian. I have not audited the accompanying initial guardianship plan. The undersigned attorney represents that he/she has examined the contents of this plan and that it conforms to the requirements of the Florida Guardianship Law.