It is enacted by the General Assembly as follows:

SECTION 1. Sections 33-15-4, 33-15-7, 33-15-17.1, 33-15-26.1 and 33-15-47 of the General Laws in Chapter 33-15 entitled "Limited Guardianship and Guardianship of Adults" are hereby amended to read as follows:

{ADD 33-15-4. Limited guardianship. -- ADD} (1) Absent a finding, based on {DEL the functional DEL} {ADD a decision-making ADD} assessment, that an individual is totally incapacitated, the court shall limit the scope of the powers and duties of a guardian to the terms best suited to allow the individual found partially incapacitated to participate as fully as possible in decisions affecting him or her. The court shall not appoint a guardian or limited guardian if the court finds that the needs of the proposed ward are being met or can be met by a less restrictive alternative or alternatives. The court shall authorize the guardian to make decisions for the individual in only those areas where the court finds, based on {DEL the functional DEL} {ADD a decision-making ADD} assessment, that the individual lacks the capacity to make decisions. The court must strike a delicate balance between providing the protection and support necessary to assist the individual and preserving to the largest degree possible the liberty, property and privacy interests of the individual. The certificate of appointment issued to said limited guardian shall clearly state that it is limited guardianship. The court order shall clearly indicate the scope of the powers and duties of the limited guardian. The appointment of a limited guardian shall not constitute a finding of legal incompetence: An individual for whom a limited guardian is appointed shall retain all legal and civil rights except those which have been specifically suspended by the order.

(2) A {DEL functional assessment DEL} {ADD decision-making assessment tool, in the form as shown in section 33-15-47 ADD} must be filed with the petition in each case. {DEL If a functional assessment has been conducted as part of the individual's care and treatment, such functional assessment may be used as evidence to support a petition for limited guardianship or guardianship if the assessment reflects the individual's current level of functioning and includes the following components: diagnosis; medications (including dosage) and whether the individual's diagnosis includes any potentially reversible or controllable physiological or psychiatric conditions; receptive, verbal and written communication; cognitive status; behavior; and whether and how any deficits in these areas interfere with the individual's capacity to make decisions regarding health care, finances, residence or relationships; whether the individual's needs are being met at his or her current residence and whether a change in residence is recommended; alternatives to guardianship considered and investigated; scope of limited guardianship or guardianship sought. DEL}

(3) {ADD The individual's treating physician must complete the decision-making assessment tool. Professionals or other persons acquainted with the individual being assessed may also complete the decision-making assessment tool. ADD} {DEL A functional assessment may be conducted by any professional whose training and experience aid in the assessment of functional capacity. It is preferable that the functional assessment be conducted by a professional who is known to the respondent, in a setting familiar to the respondent, and at a time when the respondent is functioning at his or her best. DEL}

(4) Modification: If because of a change in the partially incapacitated individual's level of functioning, the scope and duties of the limited guardianship order no longer meet the needs of the individual and/or fail to afford the individual as much autonomy as possible, modification of the limited guardianship order is required.

(a) Modification can be accomplished by agreement of the parties: the partially incapacitated individual and his counsel, and the limited guardian. Such agreement shall be submitted to the court and entered as an order.

(b) Where no agreement can be reached, any or all of the parties may request a hearing.

{ADD However, provisions of this chapter shall not be construed to mean a person is in need of a guardian/limited guardian solely because he or she is being furnished or relies upon treatment by spiritual means through prayer alone in accordance with the tenets and practices of a church or religious denomination recognized by the laws of this state. ADD}

{ADD 33-15-7. Guardians ad litem -- Duties -- Legally incapacitated respondents right to counsel -- Termination of appointment of guardian ad litem. -- ADD}

(1) {ADD Upon the filing with the probate court clerk of a petition for the appointment of a guardian, ADD} {DEL The DEL} {ADD a ADD} guardian ad litem shall be appointed for each respondent;

(2) The guardian ad litem need not be an attorney;

(3) The duties of a guardian litem shall include all of the following:

(a) Personally visiting the respondent;

(b) Explaining to the respondent the nature, purpose, and legal effect of the appointment of a guardian;

(c) Explaining to the respondent 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;

(d) Informing the respondent of the name of the person known to be seeking appointment as guardian; and

(e) Making determinations, and informing the court of those determinations, on all of the following:

(i) Whether the respondent wishes to be present at the hearing.

(ii) Whether the respondent wishes to contest the petition.

(iii) Whether the respondent wishes limits placed on the guardian's powers; and

(iv) Whether the respondent objects to a particular person being appointed guardian.

(4) If the respondent wishes to contest the petition, to have limits placed on the guardian's powers, or to object to a particular person being appointed guardian, and, if legal counsel has not been secured, the court shall appoint legal counsel. If the respondent is indigent, the state shall bear the expense of legal counsel.

(5) If the respondent requests legal counsel, or if the guardian ad litem determines it is in the best interest of the respondent to have legal counsel, and if legal counsel has not been secured, the court shall appoint legal counsel. If the respondent is indigent, the state shall bear the expense of legal counsel.

(6) If the respondent has legal counsel appointed pursuant to subsection (2) or (3), the appointment of a guardian ad litem shall terminate.

{ADD 33-15-17.1. Notice. -- ADD} (a) No petition for limited guardian or guardian shall be heard and no person shall be appointed limited guardian/guardian of an individual unless notice of the petition for appointment of a limited guardian or guardian and a copy of the petition itself shall be served upon the respondent in person at least fourteen (14) days prior to any hearing on the petition.

(b) Such notice shall be in plain language and large type and shall include the time and place of the hearing, the possible loss of liberty if the petition is granted and shall inform the respondent of his or her rights including the court appointment of a guardian ad litem; the right to a hearing and to be present at the hearing to confront witnesses, present evidence, contest the petition, object to the appointment of a particular individual as guardian, request that limits be placed on the guardian's powers, and the right to counsel.

(c) The court officer that serves such notice shall be dressed in plain clothes. He or she shall have experience dealing with individuals who may lack decision making ability.

(d) The court officer shall present the written notice and shall also read the notice to the respondent.

(e) Notice shall be given by the petitioner or his or her attorney at least ten (10) days before the date set for hearing on the petition by regular mail, postage prepaid, addressed to {ADD (1) ADD} the respondent's spouse and {DEL children at their last known addresses, or, if there be no children, then to the respondent's DEL} heirs at law {DEL next in line DEL} (under the rules of descent) as set forth in section 33-1-1 only at their last known addresses ; and (2) the administrator of any care and treatment facility where the respondent resides or receives primary services; and (3) any {DEL current provider of primary support services and primary medical caregivers DEL} {ADD individual or entity known or reasonably known to the petitioner to be regularly providing protective services to the respondent. ADD} The petitioner or his or her attorney shall at or prior to the hearing file or leave to be filed an affidavit that such notice was given setting forth the names and post office addresses of the persons to whom the same was sent and the date of mailing thereof, together with a copy of the notice.

(f) Should the petitioner have no knowledge of the existence or whereabouts of any of the persons required to be notified pursuant to subparagraph (e) above, an affidavit to that effect filed with the court shall satisfy this notice requirement.

(g) Notwithstanding any notice requirement of the petitioner, the court shall give notice of the petition by advertisement.

{ADD 33-15-26.1. Annual status report. -- ADD} (a) A limited guardian/guardian with authority to make decisions regarding the ward's person shall return to the probate court, in every year, {DEL a report DEL} {ADD the annual status report, in the form as shown in section 33-15-47 ADD} regarding the status of the ward; the report shall include the following information:

(1) the residence of the ward;

(2) the condition of the ward;

(3) any changes the limited guardian/guardian perceives in the decision making capacity of the ward; and

(4) a summary of actions taken and decisions made on behalf of the ward by the limited guardian/guardian.

(b) The probate court shall monitor each limited guardianship/guardianship file. If the court finds that the required annual status report has not been filed, the court shall cite the limited guardian/guardian and demand that the status report be filed within thirty (30) days.

{ADD 33-15-47. Forms. -- ADD} The following forms shall be used for the purposes of this chapter:

Respondent lacks decision-making ability in one or more of the following areas as indicated:

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:

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 guardianship 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.

{ADD The Respondent has the following heirs at law: ADD}

{ADD ____________________________ ADD}

{ADD Signature ADD}

{ADD Subscribed and sworn to before me as to the truth of the above facts by in on the day of , 19 . ADD}

{ADD _____________________________ ADD}

{ADD Notary Public ADD}

{ADD _____________________________ ADD}

{ADD Print Name ADD}

{ADD DECREE ADD}

{ADD __________________ ADD} {ADD ___________________ ADD} {ADD Dated ADD} {ADD PROBATE JUDGE ADD}

{ADD This notice should be served at once and returned to the clerk of the court. ADD}

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

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 .

The Petition requests that the Probate Court consider the qualification of the following individual/agency to serve as your limited guardian/guardian:

{ADD ADD}

{ADD ADD}

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 {DEL administration DEL} {ADD administrator ADD} of any care or treatment facility where you live or receive primary services; your spouse, {DEL children DEL} and heirs at law; {DEL your next of kin; any other appropriate DEL} {DEL person; and any provider of support services and your medical DEL} {DEL caregivers. DEL} {ADD any individual or entity known to petitioner ADD} {ADD to be regularly supplying protection services to you. ADD}

I certify that I hand-delivered and read this Notice. {ADD to ADD}

{ADD on the day of , 19 . ADD}

{DEL I certify that copies of the notice of this proceeding have been mailed DEL}

{ADD I certify that, as required by Rhode Island General Laws section 33-15-17.1(e), I mailed a copy of this Notice to the following persons, at the addresses listed, on the day of , 19 . ADD}

{ADD subscribed and sworn to before me this day of 19 ADD}

{ADD Judge of the Probate Court of the of this day of , 19 . ADD}

A tool designed to assist in determining whether an individual needs a limited guardian or guardian

(I) GENERAL INFORMATION

Name of Individual:

Address of Individual:

If this is a care and treatment facility, state the name of the facility and the type of care and treatment provided.

How long has the individual resided at the above address?

{ADD ADD}

Primary physician's name:

Date last seen by primary physician:

Please summarize the problems the individual is having with decision making. Indicate how long the individual has had these problems and list any steps taken to resolve these problems.

{ADD ADD}

{ADD ADD}

Name and job title of person doing assessment:

{ADD ADD}

Date of assessment:

Type of association/relationship?

How long have you known the individual and in what capacity?

{ADD ADD}

(II) ASSESSMENT

(A) Diagnosis:

{ADD ADD}

(1) Does the individual's diagnosis include any potentially reversible controllable physiological or psychiatric conditions that interfere with an individual's decision making capacity.

{ADD ADD}

{ADD ADD}

List medications (include dosage):

{ADD ADD}

(a) Has a review been conducted to determine whether the dosage of any mind altering medications is excessive?

{ADD ADD}

(b) Please describe the scope of the review, the results of the review and the date of the review.

{ADD ADD}

{ADD ADD}

(B) Functional Diagnosis

Can the individual walk without assistance?

If the individual needs assistance to ambulate, please describe:

{ADD ADD}

Can the individual prepare meals without assistance?

If the individual needs assistance with the preparation, please describe:

{ADD ADD}

Are the individual's nutrition needs being met?

Can the individual dress and undress independently?

If the individual needs assistance dressing or undressing, please describe:

{ADD ADD}

Does the individual wear weather appropriate clothing?

Can the individual maintain a residence independently?

If the individual needs assistance maintaining a residence, please describe:

{ADD ADD}

Can the individual keep a healthy and safe environment independently?

{ADD ADD}

If the individual needs assistance keeping a healthy and safe environment, please describe:

{ADD ADD}

Does the individual have relationships with family and friends in his/her community?

(C) Communication Skills

For the skill areas that follow, please check each statement that describes this individual. If the individual has a deficit in the skill area listed, please indicate how this deficit interferes with the individual's decision making ability.

(1) Receptive Communication

Understands complex instructions and remembers them for at least 24 hours.

Understands simple two step directions but quickly forgets them.

Does not appear to understand any verbal communication, but can respond to gestures.

Does not appear to understand even simple gestures (i.e. come here, sit down, etc.)

Please list any physical disabilities or language barriers which might impact the individual's receptive communication and steps taken to remove or reduce any adverse impact:

{ADD ADD}

{ADD ADD}

If there is a deficit in receptive communication skills, how does this interfere with the individual's capacity to make decisions regarding health care?

finances?

residence?

relationships?

If there is a deficit, is it treatable or reversible?

{ADD ADD}

(2) Verbal Communication

Carries on complex conversation involving abstract ideas.

Carries on simple conversation involving routine matters.

Uses two word sentences (i.e. come here, give me, etc.).

Uses only monosyllables (i.e. yes, no, eat, etc.).

Able to talk, but conversation or response to questions is irrelevant or off the topic.

Uses gestures to converse or respond to questions.

Does not communicate by word or gesture.

Please list any physical disabilities or language barriers which might impact the individual's expressive communication and steps taken to remove or reduce any adverse impact.

{ADD ADD}

If there is a deficit in expressive communication skills, how does this interfere with the individual's capacity to make decisions regarding health care?

{ADD ADD}

finances?

residence?

relationships?

If there is a deficit, is it treatable or reversible?

{ADD ADD}

(3) Written Communication

Briefly describe the individual's ability to read:

{ADD ADD}

Briefly describe the person's ability to write:

{ADD ADD}

Please list any physical disabilities or language barriers which might impact the individual's written communication and steps taken to remove or reduce any adverse impact:

{ADD ADD}

If there is a deficit in written communication skills, how does this interfere with the individual's capacity to make decisions regarding health care?

{ADD ADD}

finances?

residence?

relationships?

If there is a deficit, is it treatable or reversible?

{ADD ADD}

(D) Cognitive Status

Is living in the present and aware of his/her present condition.

Knows where he/she is (i.e. to state, residence).

Recognizes relative or friends.

Knows names of relatives or friends.

Knows which service providers to look to for what.

Recognizes service providers.

Knows names of service providers.

Responds to own name.

Needs simple reality orientation (being reminded of name, day of week, where he or she is, etc.).

Needs to be reminded about daily activities (i.e. meal times, bathing, bedtime, etc.).

Can negotiate environment (can find bedroom, bathroom, dining room, etc.).

Needs to be led from place to place.

{ADD ADD}

{ADD ADD}

{ADD ADD}

{ADD ADD}

If there is a deficit in cognitive status, how does this interfere with the individual's capacity to make decisions regarding health care?

{ADD ADD}

finances?

residence?

relationships?

f there is a deficit is it treatable or reversible?

(E) Behavior

Relates well to others.

Becomes suspicious or quarrelsome with little or no provocation.

Inappropriate and/or repetitive movements are present (i.e. rocking, hand wringing, etc.).

Other disruptive or inappropriate behaviors are present (please give examples):

{ADD ADD}

{ADD ADD}

Depressed

Disruptive

Paranoid

If there is a deficit in social behavior how does this interfere with the individual's capacity to make decisions regarding health care?

(III) DEMONSTRATION OF DECISION MAKING CAPACITY

(A) Health Problems

Indicates when he or she has a health problem.

Schedules medical and dental appointments for checkups.

Requests medical and dental appointments for problems.

Takes prescription medications as prescribed.

Takes over the counter medicine as recommended.

Handles medical and dental appointments independently.

Requires assistance keeping medical and dental appointments.

Indicates verbally or by gesture if in pain.

{ADD ADD}

finances?

residence?

relationships?

If there is a deficit, is it treatable or reversible?

(B) Health Care Decisions

Gathers information regarding proposed medical treatment.

Weighs risks and benefits of medical treatment before making a choice regarding proposed treatment.

Considers prognosis with and without treatment before making a choice regarding proposed treatment.

Expresses choices about medical treatment (i.e. chooses between alternative proposed treatment,

If the individual does not take the foregoing steps before making decisions regarding proposed medical treatment, please describe how the individual responds when medical treatment is proposed.

{ADD ADD}

{ADD ADD}

If there is a deficit in the individual's ability to provide informed consent to medical care, does this place the individual at risk of harm to his or her personal welfare?

If yes, please explain:

{ADD ADD}

If there is a deficit, is it treatable or reversible?

Manages spending money independently.

Needs assistance with spending money.

Pays bills independently.

Needs assistance paying bills.

Needs assistance with banking.

Manages personal property independently.

Needs assistance managing personal property.

Manages real property independently.

Needs assistance managing real property.

Manages income independently.

Needs assistance managing income.

If there is a deficit in the individual's ability to manage money, does the individual need more assistance than he or she is currently receiving?

If so, please describe any additional assistance needed.

{ADD ADD}

(D) Financial Decision Making/legal Matters

Gathers information before making financial decisions.

Makes financial decisions.

Does not gather information before making financial decisions.

Does not make financial decisions.

Requests assistance when needed regarding financial decision making.

Does not request assistance regarding financial decisions.

Requests legal advice when necessary.

Does not request legal advice when necessary.

Hires an attorney to represent him/her when necessary.

Does not hire an attorney to represent him/her when necessary.

Express instruction to the attorney.

Reviews legal documents before determining whether to sign them.

Does not review legal documents before determining whether to sign them.

Does not make decisions regarding legal matters.

Please give examples of any actions this individual has taken on legal matters.

{ADD ADD}

{ADD ADD}

If there is a deficit in the individual's ability to make decisions about his or her finances or legal affairs, describe the degree of assistance the individual needs with financial or legal decision making.

{ADD ADD}

(E) Residence

Makes decisions regarding where to live. Needs assistance making decisions regarding where to live.

Describe assistance needed:

{ADD ADD}

Seeks assistance making decisions regarding where to live.

Needs are being met at current residence.

Individual expresses desire to live in a

Needs could be met in a less restrictive setting.

Individual expresses desire to remain at current residence.

Needs are not being met at current residence.

Describe any unmet residential needs:

{ADD ADD}

{ADD ADD}

Needs can be met by additional support services.

Needs cannot be met at current residence, a change in residence is recommended.

Individual expresses desire to change residence so needs can be met.

If a change in residence is recommended, please indicate the appropriate residential alternative:

Private residence.

Rooming house.

Supervised apartment.

Halfway house.

Group home.

Residential care/assisted living (formerly shelter care).

Nursing facility.

Long term care facility.

Hospital.

Other (please list):

Is the recommended alternative currently available?

If there is a deficit in the individual's ability to make decisions concerning where he/she lives, does this deficit place the individual at risk of harm to his/her personal welfare?

{ADD ADD}

(F) Relationships

Individual makes decision regarding with whom he/she will associate.

Individual needs assistance making decisions regarding with whom he or she will associate.

Individual seeks assistance making decisions regarding with whom he or she will associate.

If there is a deficit in the individual's ability to make a decision regarding relationships, does this deficit place the individual at risk of harm to his or her personal or financial welfare?

If yes, please explain:

{ADD ADD}

(IV) ALTERNATIVES TO GUARDIANSHIP

If the individual lacks decision making ability, he or she may require assistance in making decisions concerning health care, finances, residence and relationships. The law requires that less restrictive alternatives to guardianship be considered and investigated before proceeding with the guardianship process. A guardian will not be appointed if the individual's needs are being met or can be met by a less restrictive alternative to guardianship.

Are there any less restrictive alternatives to guardianship that will assist this individual in making decisions in those areas that the individual lacks decision making ability?

{ADD ADD}

Has any such alternative been considered and investigated? Please explain:

{ADD ADD}

If no alternatives to guardianship have been sought, why not?

{ADD ADD}

{ADD ADD}

(V) SCOPE OF GUARDIANSHIP

If there are no less restrictive alternatives that will assist this individual in making decisions in those areas that the individual lacks decision making ability and guardianship is sought, Rhode Island law requires that the guardianship be limited to assist the individual in only those areas where the individual lacks decision making ability. The goal is to provide the protection and support necessary to assist the individual while preserving to the largest degree possible the individual's autonomy.

Please indicate those areas where th individual lacks decision making ability and his or her needs cannot be met by a less restrictive alternative to guardianship.

Health problems.

Routine medical care. Intrusive or surgical interventions.

Seeking admission to care and treatment facility.

Authorizing access to confidential health care information.

Managing spending money.

Paying bills

Handling banking.

Personal budget.

Household budget.

Managing real property.

Managing income.

Managing business matters.

Making gifts.

Reviewing routine legal documents.

Seeking legal advice.

Seeking legal representation.

Instructing attorney.

Decisions regarding where to live.

Maintaining healthy and safe environment.

Seeking appropriate support services.

Decisions regarding relationships.

Other (list)

State specific evidence of the individual's lack of decision making capacity in the categories indicated above:

{ADD ADD}

{ADD ADD}

(VI) PROSPECTIVE GUARDIANS

Name:

Address:

Telephone:

Relationship to individual:

Name:

Address:

Telephone:

Relationship to individual:

Attach additional sheets if necessary.

{ADD ADD}

Signature of person doing assessment DEL}

{ADD Name of Individual being assessed: ADD} {ADD Current Address: ADD}

{ADD Instructions for Completion ADD}

{ADD 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 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 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 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. ADD}

{ADD THE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON ADD} {ADD ADD} {ADD (DATE) ADD}

{ADD 1. DIAGNOSIS and PROGNOSIS:

(2) MEDICATIONS (PLEASE LIST):

How do the above medications, if any, affect the individual's decision-making ability? Please explain:

(A) Intact;(B) Mild Impairment;(C)Moderate Impairment;(D) Severe Impairment

(A)Intact; (B) Mild Impairment; (C) Shifting/Wandering; (D)Delirium; (E) Unresponsive

(A) Intact; (B) Able to Make Most Decisions; (C) Impaired; (D) Gross Impairment

(A) Intact (B) Sensory Deficits (Hearing/Speech/Sight)

(C) Impairment In Comprehension/Speech: Mild/Moderate/Severe

(D) completely Unresponsive

(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:

(A) Intact/Exercises (B) Drives Car Or Uses Public Transportation

(C) Independent Ambulation in Home Only; (D) Walker/Cane; (E) Requires Assistance

If you circled (C), (D), or (E), is situation treatable or reversible? If so, how?

(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?

(A) No Active Problem; (B) Initiates Problem Identification; (C) Actively Cooperative; (D) Passively Cooperative; (E) Passively Uncooperative; (F) Actively Uncooperative

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

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:

(A) FINANCIAL MATTERS

(B) HEALTH CARE MATTERS

(C) RELATIONSHIPS

(D) RESIDENTIAL MATTERS ADD}

{ADD (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.)" ADD}

{ADD (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. ADD}

{ADD ADD}

{ADD Signature ADD}

{ADD ADD}

{ADD Name (Print or Type) ADD}

{ADD ADD}

{ADD Title ADD}

{ADD Date: ADD}

{ADD Names and titles of others who assisted in Preparation of This Assessment. ADD}

{ADD STATE OF RHODE ISLAND ADD} {ADD PROBATE COURT OF THE ADD}

{ADD Estate of ADD} {ADD Docket No. ADD}

{ADD (1) The residence of the ward is ADD}

{ADD (2) The medical condition of the ward is ADD}

{ADD ADD}

{ADD ADD}

{ADD ADD}

{ADD (3) I perceive the following changes in the decision making capacity of the ward: ADD}

{ADD ADD}

{ADD ADD}

{ADD ADD}

{ADD (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: ADD}

{ADD ADD}

{ADD ADD}

{ADD ADD}

{ADD (If more space is needed, please attach a supplement). ADD}

{ADD ADD}

{ADD Guardian ADD}

{ADD Date: ADD}

SECTION 2. This act shall take effect upon passage.