RI Gen L § 33-15-47 (2021)
2021 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     ____________     20__________   PETITION FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP Petitioner hereby petitions the Probate Court of the 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 Date, which functional assessment reflects the current level of functioning of Respondent, it has been determined that 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:  □ No conflict of interest that would interfere with guardianship     duties   □ No criminal background that would interfere with guardian-    ship duties   □ The capacity to manage financial resources involved.   □ The ability to meet requirements of law and unique needs of     individual.   □ 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 ____, 20__.     _________      Notary Public      _________      Print Name    DECREE     _________    _________     Dated  PROBATE JUDGE   This notice should be served at once and returned to the clerk of the court.NOTICESTATE OF RHODE ISLAND BY THE PROBATE COURT OF THE ______ OF ______ BY THE COUNTY OF _____________________________________ AND STATE AFORESAID To _____________________________________  Estate or _____________________________________  Docket No. _____________________________________  GREETING: 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   Petitionera limited guardian/guardian for you.A hearing regarding this Petition shall be held On: _____________________________________________________________________  date At: _____________________________________________________________________  timeat 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.CERTIFICATION OF SERVICE I certify that I hand-delivered and read this Notice to _____________________________________ on the _________ day of ___________________ , 20 _________ .     _________     Signature     _________     Print Name     _________     Address   CERTIFICATION OF NOTICE 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 ___________________ , 20 _________ .      _________     Signature     _________     Print Name     _________     Address   Subscribed and sworn to before me this _________ day of ___________________ , 20 _________ .     _________     Notary Public   WITNESS Judge of the Probate Court of the _____________________________________ of _____________________________________ this _________ day of ___________________ , 20 _________ .     _________     Clerk   DECISION-MAKING ASSESSMENT TOOL   Name of Individual being assessed: Current Address:    _____________________________________    _____________________________________________________________________       _________    Date of Birth:  Permanent Address (if different):    _____________________________________    _________       _________    Instructions for Completion 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.  A. BIOLOGICAL ASSESSMENT 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:  _________   _________   _________   _________   _________  B. PSYCHOLOGICAL ASSESSMENT 1. MEMORY (CIRCLE ONE) (A) Intact; (B) Mild Impairment; (C) Moderate Impairment; (D) Severe Impairment 2. ATTENTION (CIRCLE ONE) (A) Intact; (B) Mild Impairment; (C) Shifting/Wandering; (D) Delirium; (E) Unresponsive 3. JUDGMENT (CIRCLE ONE) (A) Intact; (B) Able to Make Most Decisions; (C) Impaired; (D) Gross Impairment 4. LANGUAGE (CIRCLE ALL THAT APPLY) (A) Intact (B) Sensory Deficits (Hearing/Speech/Sight) (C) Impairment In Comprehension/Speech: Mild/Moderate/Severe (D) Completely Unresponsive 5. EMOTION (CIRCLE ALL THAT APPLY) (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:  C. SOCIAL ASSESSMENT 1. MOBILITY (CIRCLE ALL THAT APPLY) (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?  _________   _________   _________   _________   _________  2. SELF CARE (CIRCLE ALL THAT APPLY) (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? _________  3. CARE PLAN MAINTENANCE (CIRCLE ALL THAT APPLY) (A) No Active Problem; (B) Initiates Problem Identification; (C) Actively Cooperative; (D) Passively Cooperative; (E) Passively Uncooperative; (F) Actively Uncooperative  4. SOCIAL NETWORK RELATIONSHIPS(CIRCLE ONE IN (A) AND ONE IN (B)) (A) 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  D. SUMMARY 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 MATTERSYes No Limited   _________   _________   _________   _________   _________  (2) HEALTH CARE MATTERSYes No Limited   _________   _________   _________   _________   _________  (3) RELATIONSHIPSYes No Limited   _________   _________   _________   _________   _________  (4) RESIDENTIAL MATTERSYes 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. _________    ANNUAL STATUS REPORT (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. _________    REPORT OF THE GUARDIAN AD LITEM 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.