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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.

NOTICE

STATE 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

Petitioner

a limited guardian/guardian for you.

A hearing regarding this Petition shall be held

On: _____________________________________________________________________

date

At: _____________________________________________________________________

time

at 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)

(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

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.

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