Fillable CAPL Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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CAPL Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 1 of 8
CAPL
Your Name: _________________________
Address: ____________________________
City, State, Zip: ______________________
Phone: ______________________________
Email: ______________________________
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult who needs a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
PLAN OF CARE FOR THE PROPOSED PROTECTED ADULT PERSON
I/we, (name of proposed guardian) ________________________________________
and (name of second proposed guardian, or “n/a”) ___________________________________
am/are petitioning to be the Guardians of the above-named proposed protected person. I/we
have determined that the following plan of care is the appropriate level of care for the proposed
protected person and this plan of care serve’s their best interests.
I. Alternatives
1. Before filing for guardianship, I tried the following to avoid the need for a court-
appointed guardian: (explain how you tried to handle the proposed protected person’s
needs before you filed a request to be appointed the guardian)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 2 of 8
II. Living Arrangements
2. The proposed protected person is (name) _____________________________________.
His / her birthdate is (date of birth) ___________________________, and he / she is
(age) ______ years old.
3. The proposed protected person’s current address and phone number is:
___________________________________________________
Name of Facility (if applicable)
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
___________________________________________________
Telephone number
4. He / she has been at the above address since (date) ___________________.
5. The address listed in item #1 is best described as: ( check one)
Living alone in the proposed protected person’s own single family home,
apartment, or condominium.
Living with another person or persons in the proposed protected person’s own
single family home, apartment, or condominium. List the names of all
individuals living in this home (names): ________________________________
__________________________________________________________.
The proposed protected person lives with a relative or friend in a single family
home, apartment, or condominium. The proposed protected person lives with
(names): _______________________________________________________.
An assisted living facility.
A skilled nursing home.
A licensed group home.
A medical facility, hospital, or psychiatric facility.
A secured perimeter facility.
Other (explain): _______________________________________.
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 3 of 8
6. The proposed protected person: ( check all that apply)
Will continue to live in their own residence or a friend/family’s residence.
Will return to a private residence on (estimated date when the proposed
protected person will return to the residence and provide the address):
____________________.
Is able to live in a private residence with assistance. The proposed protected
person requires the following level of in-home assistance (describe):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Is not able to live in any private residence because (describe the reasons why the
proposed protected person is not able to live in a private residence):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
III. Physical and Mental Condition
7. The proposed protected person has the following insurance coverage for medical / dental
/ mental health services: ( check all that apply)
Medicare
Medicare Part B
Medicaid
VA Health Benefits
Prescription Drug Coverage (name of policy):
____________________________
Private Health Insurance (name of policy): ______________________________
Other (explain): ___________________________________________________
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 4 of 8
8. The proposed protected person’s physical health is ( check one)
Good
Fair
Poor
Describe the proposed protected person’s overall physical health and physical
limitations:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
9. The proposed protected person receives the following medical services: ( check all
that apply)
Regular doctor visits every (how often, i.e. “monthly” “every 3 months” etc.)
___________________________
Regular dental visits every (how often) _________________________________
Home health care every (how often) ___________________________________
Prescription medication (list medication) _______________________________
________________________________________________________________
________________________________________________________________
Full-time nursing care
Hospice care
10. The proposed protected person’s mental health is ( check one)
Good
Fair
Poor
Describe the proposed protected person’s overall mental health:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 5 of 8
11. The proposed protected person receives the following mental health services: ( check
all that apply)
Behavioral health visits every (how often, i.e. “monthly” “every 3 months” etc.)
___________________________
Psychiatric appointments every (how often) _____________________________
Prescription medication (list medication) _______________________________
________________________________________________________________
________________________________________________________________
12. The proposed protected person requires the following medical or mental health
examinations to determine necessary and/or ongoing treatment needs (describe any
medical tests / appointments that are needed):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
IV. Personal Care
13. The proposed protected person’s personal care needs are: ( check all that apply)
No assistance is needed in performing activities of daily living.
Personal caregivers are needed. Caregivers are needed an average of (number)
______ hours per week. Caregivers provide assistance with the following
activities of daily living (explain what assistance is provided, such as
housekeeping, bathing, meal preparation, etc.) ___________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Assistance with medication is required.
24-hour assistance is needed.
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 6 of 8
V. Proposed Protected Person’s Wishes
14. The proposed protected person signed the following legal documents to indicate what
kind of care he/she would like if he/she ever became incapacitated: ( check all that
apply)
Written care plan. The plan states that the proposed protected person’s desires in
the event of incapacity are: (explain) ____________________________________
_________________________________________________________________
_________________________________________________________________
Durable power of attorney for health care. The agent appointed by the proposed
protected person is (name) __________________________________.
Durable power of attorney for financial matters. The agent appointed by the
proposed protected person is (name) _______________________________.
Revocable or living trust. The agent appointed by the proposed protected person is
(name) ______________________________________.
Other estate planning document: (describe) ______________________________.
None of the above.
15. Consultation with proposed protected person: ( check one)
I have talked with the proposed protected person about how he/she would like to
be cared for. The proposed protected person’s wishes are (explain)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
I have not talked with the proposed protected person about how he/she would like
to be cared for because (explain why you have not asked the person about their
wishes)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 7 of 8
16. Compliance with proposed protected person’s wishes: ( check one)
To the extent possible, I am honoring the proposed protected person’s wishes.
I have not been able to honor the proposed protected person’s wishes because
(explain)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
VI. Activities & Recreation
17. The proposed protected person’s recreation and social activities include: ( check all
that apply)
Group outings. (Describe) ___________________________________________
_________________________________________________________________
_________________________________________________________________
Family gatherings. (Describe) ________________________________________
_________________________________________________________________
_________________________________________________________________
Senior community center events. (Describe) ____________________________
_________________________________________________________________
_________________________________________________________________
Work and/or training program. (Describe) _______________________________
_________________________________________________________________
_________________________________________________________________
Events at assisted living facility or nursing home. (Describe) ________________
_________________________________________________________________
_________________________________________________________________
© 2018 Family Law Self-Help Center Plan of Care (Adult)
Page 8 of 8
VII. Other Information
18. The guardian(s) would like the court to know the following: (explain anything else that
the court should know about the proposed protected person)
I/We declare under penalty of perjury under the law of the State of Nevada that
the foregoing is true and correct.
DATED (month) ________________________ (day) _______, 20___.
(Second Proposed Guardian’s Signature)
(Printed Name)
(First Proposed Guardian’s Signature)
(Printed Name)
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CAPL Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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Completed 15 January 2021

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