Initial Guardianship Plan - Eleventh Judicial Circuit of Florida

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT, IN AND FOR MIAMI-DADE COUNTY, FLORIDA, PROBATE DIVISION

IN RE: GUARDIANSHIP OF:

Section:

Case Number: YYYYNNNNNN@ (@ = GD, MH or CP)

Guardianship Type:

Amended Form?

Amended Form Version:

INITIAL GUARDIANSHIP PLAN

Plan Period From:

Plan Period To:

Guardianship Inception Date:

Date of Order of Incapacity:

Guardian Name:

Guardian of the person of:

submits the following Initial Guardianship Plan for the Ward:

1. The Ward's present location is:

Facility Name / Name of Caregiver with whom the Ward resides:

Facility Type:

Phone Number:

Street Address:

City:

State:

Zip:

2. The Guardian for the plan period proposes the following as to the provision of medical and rehabilitative services for the Ward:

Physical Therapy

Routine examination by Dentist

Routine examination by Primary Care Physician

Routine examination by Ophthalmologist

Routine examination by Specialist Name of Specialist:

Speech Therapy

Occupational Therapy

The Ward retains the right to make their own decision

Other

Explanation required only if "other" checked:

3. The Guardian for the plan period proposes the following as to the provision of mental health services for the Ward:

Routine Examination by Psychiatrist/Psychologist

Ongoing Treatment Outpatient

Ongoing Treatment Inpatient

None

Other

Explanation required only if "other" checked:

4. The Ward presently is prescribed or takes the following types of medications:

Anti-Anxiety

Anti-Depressant

Cardiac

Diabetic

Memory Enhancement

Over the Counter

Psychotropic

Other Prescription

Explanation required only if "other" checked:

5. The guardian for the plan period proposes the following as to the provision of personal care services for the Ward:

Care Facility Nurses

Aides Family

Friends

Other

Explanation required only if "other" checked:

6. The guardian for the plan period proposes the following as to the provision of social/recreational services for the Ward:

Care Facility Nurses

Aides Family

Friends

Ward retains the right to make their own decision

Other

Explanation required only if "other" checked:

7. The Guardian for the plan period proposes the following as to the provision of social services for the Ward:

Adult Day Care

Counseling

Homemaker/Personal Care

Home Delivered Meals

Private Services

Public Services Senior

Center Sheltered

Workshop

Transportation

Volunteer Services

Other

Explanation required only if "other" checked:

8. The Guardian states the place and kind of residential setting best suited for the needs of the Ward is:

If "other" was selected from the previous list, please provide an explanation.

Explanation:

The guardian will ensure that the above is the best residential setting for the Ward by:

Periodically Assessing Needs

The Ward retains the right to decide

No change, unless required by medical condition

Other

9. The Ward has the following health insurance, accident insurance, private benefits, or governmental benefits available to meet the costs of medical, mental health, or related services:

Health Maintenance Organization (HMO)

Institutional Care Program

Optional State Supplement

Medicare

Medicaid

Pending Benefits, not yet received

Pension

Social Security

Social Security Disability Income (SSDI)

Supplemental Insurance

Supplemental Security Income (SSI)

VA

Other

10. The Guardian will secure the following physical/mental examinations to determine the Ward's medical and mental health treatment needs:

To add a record, click (+). To remove, click (-).

#

Provider's Name, Address, and Phone Number

Type of Provider

Approximate Date of Exam

1

11. To assist the Court with review of the initial plan to determine if it is in the best interest of the Ward, please provide the following information:

A. Please rate the ability of the Ward to engage in activities of daily living or instrumental activities of daily living:

Description

Rating

i. Administration of Medication

ii. Bathing

iii. Climbing Stairs

iv. Doing Laundry

v. Dressing

vi. Eating

vii. Grooming

viii. Heavy Chores

ix. Light Housekeeping

x. Managing Money

xi. Preparing Meals

xii. Shopping

xiii. Toileting

xiv. Transferring

xv. Walking/Mobility

B. The diagnosed mental disabilities of the Ward are:

Alzheimer's type of dementia

Autism Spectrum Disorders

Closed Head Injury Dementia

Depression

Developmental Disabilities

Induced by substance abuse

Schizophrenia or related disorders

Workshop

Other

Explanation required only if "other" checked:

C. The diagnosed physical disabilities of the ward are:

Mobility

Blindness

Deafness

Diabetic

Parkinson's disease

Severe arthritis

Other

Explanation required only if "other" checked:

D. The assistive devices used by the Ward are:

Crutches

Dentures

Glasses

Hearing Aid

Prosthetics

Walker/Cane

Wheelchair

None

Other

Explanation required only if "other" checked:

E. The plan for the next twelve (12) months for disaster preparedness for the Ward is:

12. Please list, for adult wards only, any preexisting orders not to resuscitate executed under §401.45(3), Fla. Stat. or preexisting advance directives as defined in §765.101, Fla. Stat., including the date an order or directive was signed, whether such order or directive has been suspended by the court, and a description of the steps taken to identify and locate the preexisting "order not to resuscitate" or "advance directives".

To add a record, click (+). To remove, click (-).

#

Title of Order/Directive

Date of Order/Directive

Suspended by Court (Yes/No)

Steps Taken to Identify and Locate Order/Directive

1

13. To assist the court in providing demographic information to private and public entities, please provide the following information:

CERTIFICATION AND SIGNATURE OF GUARDIAN(S)

(Check all that apply)

The recommendations of the examining committee are incorporated into this plan.

The Ward was declared totally incapacitated.

The Ward is a minor.

The guardian has consulted with the Ward, to the extent reasonable, has honored the Ward's wishes, and to the maximum extent possible the plan is in accordance with the Ward's wishes or consistent with the rights retained by the Ward.

The plan does not restrict the physical liberty of the Ward except as necessary to protect the Ward and others from serious physical injury, illness, or disease.

The plan provides for the Ward's medical care and mental health treatment.

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

Guardian Signature:

Guardian Name:

Date signed by Guardian:

Guardian Taxpayer Identification #:

Guardian's Email Address:

Guardian Mailing Address:

City:

State:

Zip:

Co-Guardian

Co-Guardian Signature:

Co-Guardian Name:

Date signed by Co-Guardian:

Co-Guardian Taxpayer Identification #:

Co-Guardian's Email Address:

Co-Guardian Mailing Address:

City:

State:

Zip:

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.

Preparer Signature:

Preparer Name:

Date signed by Preparer:

Preparer Taxpayer Identification #:

Preparer's Email Address:

Preparer Mailing Address:

City:

State:

Zip:

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.

Attorney Signature:

Attorney Name:

Date signed by Attorney:

Attorney Bar Number:

Attorney's Email Address:

Attorney Mailing Address:

City:

State:

Zip: