Form Adopted for Mandatory Use
Judicial Council of California
GC-335 [Rev. January 1, 2019]
CAPACITY DECLARATION—CONSERVATORSHIP
Probate Code, §§ 811, 813, 1801,
1825, 1881, 1910, 2356.5
www.courts.ca.gov
Page 1 of 3
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
CONSERVATEE PROPOSED CONSERVATEE
FOR COURT USE ONLY
CASE NUMBER:
CAPACITY DECLARATION—CONSERVATORSHIP
ATTORNEY OR PARTY WITHOUT ATTORNEY
STATE: ZIP CODE:CITY:
STREET ADDRESS:
FIRM NAME:
NAME:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
STATE BAR NUMBER:
GC-335
TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER
A.
1.
ABILITY TO ATTEND COURT HEARING
CONSERVATORSHIP OF THE OF (Name):
PERSON ESTATE
The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply):
is able to attend a court hearing to determine whether a conservator should be appointed to care for him or her. The court
hearing is set for (date): . (Complete item 5, then sign and file page 1 of this form.)
B.
has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3, and file pages 1
through 3 of this form.)
C.
has a major neurocognitive disorder (such as dementia) and, if so, (1) whether he or she needs to be placed in a secured-
perimeter residential care facility for the elderly, and (2) whether he or she needs or would benefit from medication for the
treatment of major neurocognitive disorders (including dementia). (Complete items 6 and 8 of this form and complete form
GC-335A; sign and attach form GC-335A. File pages 1 through 3 of this form and file form GC-335A.)
(If more than one item is checked above, sign the last applicable page of this form or, if item C is checked, form GC-335A.
File page 1 through the last applicable page of this form; if item C is checked, file form GC-335A as well.)
COMPLETE ITEMS 1–4 OF THIS FORM IN EVERY CASE.
GENERAL INFORMATION
(Name):
2.
(Office address and telephone number):
3. I am
a.
physician psychologist acting within the scope of my license
with at least two years' experience in diagnosing and treating major neurocognitive disorders (including dementia).
4.
(Proposed) conservatee (name):
a.
I last saw the (proposed) conservatee on (date):
The (proposed) conservateeb.
is is NOT a patient under my continuing treatment and care.
5.
A court hearing on the petition for appointment of a conservator is set for the date indicated in item A above. (Complete a. or b.)
a. The proposed conservatee is able to attend the court hearing.
b.
Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items below
that apply)
(1)
on the date set (see date in box in item A above).
(2)
for the foreseeable future.
(3)
(date):
until
(4)
Supporting facts (State facts in the space below or check this box
and state the facts in Attachment 5.)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF DECLARANT)
a California-licensed
b.
an accredited practitioner of a religion that calls for reliance on prayer alone for healing. The (proposed) conservatee is an
adherent of my religion and is under my care. (Practitioner may make ONLY the determination in item 5.)
