Fillable Initial Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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Initial Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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BROWSE PINELLAS COUNTY CLERK OF THE CIRCUIT COURT AND COMPTROLLER FORMS

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Page 1 of 11
Initial Guardianship Plan
(Pursuant to F.S. 744.632, this Report with Original Signatures is due
within 60 days after the Letters of Guardianship are signed)
In the Circuit Court, Sixth Judicial Circuit, Florida
Select County: Select County
This Report, with original signatures, is due within 60 days after the Letters of
Guardianship are signed and remains in effect until it is amended or replaced by the approval of an Annual
Guardianship Plan.
The ward is living:
In a private residence leased or owned by them (house, condo or apartment).
In a private residence not leased or owned by them (such as family member).
In a facility (Skilled Nursing, Assisted Living, etc).
Address and Phone Number where Ward is currently residing:
Address:
City, State, ZIP:
Phone:
Mailing Address for Ward (if different from above):
Mailing Address:
City, State, ZIP:
The guardian(s) submit(s) and propose(s) the following initial plan.
1.
List any preexisting orders not to resuscitate executed under s. 401.45(3) or preexisting advance
directives, as defined in s. 765.101, 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 directive. Attach additional pages to the end of the
plan, if needed.
For Official Use Only:
IN RE: GUARDIANSHIP OF:
Social Security Number:
Case Number:
For the period:
through
Guardianship Inception Date:
Date Letters were signed:
Indicate if this is a Successor Guardianship:
Guardian Name(s):
Attorney Name:
Initial
Pinellas
Ward Name:
Case Number:
Page 2 of 11
2.
The guardian states the place and kind of residential setting best suited for the needs of the Ward is:
Assisted Living (ALF)
Group Home
Intermediate
Private Residence
Skilled Nursing
Specialized
State Hospital
Other (Please Explain Below)
Explanation:
3.
For the plan period, the guardian proposes the following as to the provision of medical services for the
Ward:
Routine examination by primary care physician
Routine examination by dentist
Routine examination by Ophthalmologist
Routine examination by Specialist – area of specialty:
Physical Therapy
Speech Therapy
Occupational Therapy
The ward retains the right to make their own decision
Other: (Please Explain Below)
Explanation:
4.
For the plan period, the guardian 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 (Please Explain Below)
Other (Please Explain Below)
Explanation:
5.
For the plan period, the guardian proposes the following as to the provision of personal care of the ward,
such as bathing, grooming and feeding:
Care Facility
Nurses and Aides
Family and Friends
Other (Please Explain Below)
Explanation:
Ward Name:
Case Number:
Page 3 of 11
6.
For the plan period, the guardian proposes the following to provide for socialization and/or recreational
services for the Ward for the plan period. (i.e.: arranging friends and family to visit, encourage
participation in facility or day program activities, etc.):
Care Facility
Nurses and Aides
Family and Friends
Day Program
The Ward retains the right to make their own decision
Other (Please Explain Below)
Explanation:
7.
The Ward has the following health insurance, accident insurance, private benefits, or governmental
benefits to which the Ward is receiving to meet any part of the costs of medical, mental health or related
services:
Social Security
Social Security Disability Income (SSDI)
Health Maintenance Organization (HMO)
Supplemental Security Income (SSI)
Optional State Supplement
Institutional Care Program
Supplemental Insurance
Pension
Medicare
Medicaid
VA
Trusts (Please explain the type of Trust and how it covers costs below)
Pending Benefits (Please explain why ward is not yet receiving or provide date applied for below)
Other (Please Explain Below)
Explanation:
Ward Name:
Case Number:
Page 4 of 11
9.
The guardian will secure or has secured the following physical and/or mental examinations to determine
the Ward’s medical and mental health treatment needs:
Data Entry Format:
1
st
Line input: Provider’s first name, last name, and middle initial
2
nd
Line input: Street Address
3
rd
Line input: City, State and Zip Code
4
th
Line input: Phone Number
Type of
Provider
Approximate
Date of
Exam
1
2
3
4
5
6
7
8
9
10
Ward Name:
Case Number:
Page 5 of 11
10.
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 (ADL’s):
Light Housekeeping
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Administration of Medication
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Managing Money
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Bathing
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Prepare Meals
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Climbing Stairs
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Shopping
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Doing Laundry
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Toileting
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Dressing
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Transferring (from wheelchair to chair/bed)
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Eating
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Walking Mobility
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Grooming
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Heavy Chores
Ward needs no help
Ward needs some assistance
Ward cannot do at all
Ward Name:
Case Number:
Page 6 of 11
B. The 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
Other (Please Explain Below)
Explanation:
C. The physical disabilities of the Ward are:
Mobility
Blindness
Deafness
Diabetic
Parkinson’s disease
Severe arthritis
Other (Please Explain Below)
Explanation:
D. The assistive devices used by the Ward are (devices currently being used by the ward):
Dentures
Hearing Aid
Wheelchair
Walker/Cane
Crutches
Prosthetics
Glasses
None
Other (Please Explain Below)
Explanation:
Ward Name:
Case Number:
Page 7 of 11
11. There are NO pre-existing orders Not To Resuscitate (a/k/a “DNR”) or any other advance
directive and I have taken the following steps to verify there are none: (check all that apply)
Search of ward’s prior and current residence
Inventory of ward’s safe deposit box
Interviewed family and friends
Requested documents from the ward’s medical providers
Requested documents from the ward’s attorney
The ward executed the following advanced directives:
Order Not to Resuscitate, F.S. 401.45(3) ( a/k/a “DNR”)
Advanced Directive for Healthcare (including but not limited to: healthcare
surrogate, living will or anatomical gift)
Durable Power of Attorney, F.S., Chapter 709
Other:______________________________________________________
For ANY advanced directive listed above:
Title of the order or directive: __________________________________________
Date executed/signed: ________________________________________________
Name of Person who signed: ___________________________________________
Name of Designated Agent(s) or Surrogate(s):_____________________________
Name of any Alternate Agent(s) or Surrogate(s): ___________________________
E. The assistive devices needed by the Ward are (devices needed but ward does not have them):
Dentures
Hearing Aid
Wheelchair
Walker/Cane
Crutches
Prosthetics
Glasses
None
Other (Please Explain Below)
Explanation:
F. Are the recommendations of the examining committee incorporated into this plan?
Yes No
Explanation:
Ward Name:
Case Number:
Page 8 of 11
Relationship of Agent(s) or Surrogate(s) to the Ward:_______________________
Contact information for any Agent(s) or Surrogate(s): _______________________
__________________________________________________________________
Has a Court suspended or revoked the Order/Directive: Yes No
Date of Order: _______________ entered _________________ (County/State)
******************************************************************
Title of the order or directive: __________________________________________
Date executed/signed: ________________________________________________
Name of Person who signed: ___________________________________________
Name of Designated Agent(s) or Surrogate(s):_____________________________
Name of any Alternate Agent(s) or Surrogate(s): ___________________________
Relationship of Agent(s) or Surrogate(s) to the Ward:_______________________
Contact information for any Agent(s) or Surrogate(s): _______________________
__________________________________________________________________
Has a Court suspended or revoked the Order/Directive: Yes No
Date of Order: _______________ entered _________________ (County/State)
NOTE: Per Administrative Order 2019-005, you must file a separate Disaster Plan when
filing an initial guardianship plan. The Disaster Plan shall take into account and reflect
how each ward’s special needs will be met under the plan in the event the guardian or
ward has relocated temporarily due to an emergency situation. An updated Disaster plan
will be required if the ward is moved to a new residence. AO 19-05
Ward Name:
Case Number:
Page 9 of 11
CERTIFICATION AND SIGNATURE OF GUARDIAN(S)
(Check all that apply)
If the Wards’ ability to exercise rights has changed since the Order Determining Capacity and Appointing
Guardian, the guardian must file a Petition to Remove or Petition to Restore Rights (as appropriate.)
The Ward was declared totally incapacitated and has not been given a copy of this plan.
The Ward is a minor under the age of 14 and has not been given a copy of this plan.
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 Wards’ wishes or consistent
with the rights retained by the Ward.
In exercising his or her powers, the guardian shall recognize any rights retained by the ward {FS
744.363(6)}
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 Signature
Guardian Name
Guardian SSN/EIN
Guardian Street Address
Guardian Phone Number
Guardian City/State/Zip
Date Signed
Guardian Relationship to Ward
Co-Guardian Signature
Co-Guardian Name
Co-Guardian SSN/EIN
Co-Guardian Street Address
Co-Guardian Phone Number
Co-Guardian City/State/Zip
Date Signed
Co-Guardian Relationship to Ward
Ward Name:
Case Number:
Page 10 of 11
Co-Guardian Signature
Co-Guardian Name
Co-Guardian SSN/EIN
Co-Guardian Street Address
Co-Guardian Phone Number
Co-Guardian City/State/Zip
Date Signed
Co-Guardian Relationship to Ward
Co-Guardian Signature
Co-Guardian Name
Co-Guardian SSN/EIN
Co-Guardian Street Address
Co-Guardian Phone Number
Co-Guardian City/State/Zip
Date Signed
Co-Guardian Relationship to Ward
All guardians of person must sign and provide the most current address, telephone number, and ssn. Only reports
with Original signatures will be audited by the Clerk of the Court.
Ward Name:
Case Number:
Page 11 of 11
CERTIFICATION AND SIGNATURE OF GUARDIAN’S ATTORNEY
The undersigned hereby notifies the Court of the filing of the initial guardianship plan for the period
through .
The undersigned hereby notifies the Court of the initial guardianship plan of the guardian of the person. This initial
guardianship plan is the representation of the guardian. I have not audited the accompanying initial plan. The
undersigned attorney represents that he/she has examined the contents of the initial guardianship plan and that it
conforms to the requirements of the Florida Guardianship Law and the standards for the plans in
Select County
County.
Attorney Signature
Date Signed
Attorney Name
Attorney Bar Number
Attorney Address
Attorney Phone Number
Attorney City/State/Zip
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Initial Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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