4. The place and kind of residential setting best suited for the needs of the ward is:
5. The physical and/or mental examinations necessary to determine the ward’s
medical, dental, and mental health treatment needs are:
6. Education of the ward:
Name and address of the school the ward will attend:
Grade level of ward:
Description of classes the ward will
attend: 7. Consulting with ward (Check one):
( ) a. The ward is under age 14;
OR
( ) b. The guardian attests that the guardian has consulted with the ward
(if ward is 14 years of age or older) and, to the extent reasonable, honored the ward’s wishes
consistent with the rights retained by the ward under the plan, and to the maximum extent
reasonable, the plan is in accordance with the wishes of the ward.
8. This initial plan does not restrict the physical liberty of the ward more than is
reasonably necessary to protect the ward from serious physical injury, illness, or disease and
provides the ward with medical care and mental health treatment for the ward’s physical and
mental health.
(Please use additional sheets if necessary)
Under penalties of perjury, I declare that I have completed and read the
foregoing, and the facts set forth are true, to the best of my knowledge and belief.
Signed on .....(date)......
[A certificate of service is required if ward is 14 years of age or older.]
[I certify that the foregoing document has been furnished to
by (e-mail) (delivery) (mail) (fax) on
.....(date)…...]
Guardian’s Signature
Guardian’s Printed
Name: Guardian’s
Address:
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signature
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