Probate Intake Form

Conservatorship Intake Form
Name

First NameLast Name
Address
Telephone
Spouse's Name
Address
Telephone
Character and estimated value of the property of the estate:
Personal property: $
Annual gross income: $
Real property: $
Encumbrances $
Proposed Conservatee Information
Name
Telephone
Please enter a valid phone number.
Address
Do you need to be in charge of the person or person and estate?
Resident

Resident of California andA resident of this county
Descendant

Descendant was [ ] was not survived by a stepchild or foster child or children who have been adopted by decedent but for a legal barrier:
Petitioner is a relative of the (proposed) Conservatee or is an interested person or friend of the (proposed conservatee)
Conservatee receiving or entitled to receive benefits from the U.S Department of Veterans Affairs: is not so far as is known to petitioner)
Conservatee receiving or entitled to receive benefits from the U.S Department of Veterans Affairs:

is not so far as is known to petitioner
Estimate amount of monthly benefit payable:
Member of a federally recognized Indian tribe:

YesNo
Name of tribe:
Location of tribe:
Does the proposed conservatee reside on tribal land:

YesNo
Is conservatee an adult or a married minor:

AdultMarried Minor
Explanation of why conservatee requires a conservator to properly provide for personal needs:
Explanation of why conservatee is unable to manage financial resources or resist fraud/undue influence:
If you are the spouse or domestic partner, are you a party to any action or proceeding against the (proposed) conservatee for legal separation, dissolution of marriage, annulment, or adjudication of nullity of their marriage:

YesNo
Will conservatee attend the hearing:

YesNo
Please list ALL conservatee's relatives:
Press "Enter" to enter a new line.
List of Conservatee's Relatives:
Number of Conservatee's Relatives

12345Others
Enter the Name, Relationship, Age, Address respectively.
Name Relationship Age Address
Name Relationship Age Address
Name Relationship Age Address
Name Relationship Age Address
Name Relationship Age Address
PERSONAL NEEDS
Current address of Conservatee:
Phone
Please enter a valid phone number.
Current living arrangement:

Personal residenceHome of relativeBoard & care homeAssisted livingSkilled nursing facility
The Conservatee has been at the present residence since:

MonthDayYear
If the Conservatee is in his/her personal residence, what is the current level of care:

No assistance needed at the timeHousehold help (Hours per week)Personal caregiver (Hours per week)
What will be necessary to keep the conservatee in his/her residence?
If the conservatee is not living in residence:
Plan to return Conservatee to his/her personal residence or an explanation of limitations on residence
Medical Information:

In good healthConfusion/DisorientationUnable to read/writeMemory lossDeaf or communication problemOther
Medication Details
Medication Name
Purpose
Provider name
Provider Phone Number
Please enter a valid phone number.
Last Visit

MonthDayYear
Date
Visitations
How often do you visit the Conservatee?

DailyWeeklyMonthlyOccasionallyRarely
Family and Friends' Visits Frequency:

DailyWeeklyMonthlyOccasionallyRarely
Are any visitation particularly valued or upsetting to the Conservatee?
Activities
Describe the normal activities of Conservatee:

OutingsTelevision/RadioSocialEducationalRecreationalUnwilling to participateUnable to participateOther (specify)
Special Problems
Explain how you have addressed any special needs or problems raised by the Court Investigator,
FINANCIAL NEEDS
Monthly Income
Social Security income
Income from other sources
Pension type and amount
Dividends
Veterans Benefits
Rentals
Supplemental Security Income
Other income sources
Estimated interest from investments
Estimated Monthly Income
Monthly Expenses
Income Taxes

YesNo
Enter Amount
For Example: $1200
Explain Reasons
Insurance
Homeowners
Renters
Automobile
Worker's Comp
Health
Life
Other
LIving Expenses
Rent or Mortgage
Utilities
Nursing Home or Board & Care Home:
Telephone
Additional Monthly Expenses
Live-In Attendants
Laundry and Cleaning
Other Care Providers
Clothing
Medical and Dental Supplies
Entertainment/Recreation
Food
Transportation
Other
TOTAL Estimated Monthly Expenses
If monthly expenses exceed monthly income, how do you plan to meet the shortfall?
a) For the present:
b) For the long term:
Planned Changes in Investments and Major Assets:
Safety Deposit Box Contents
Valuable Assets in Conservatee's Residence
Additional Services Needed
Is there anything else you would like me to know?

YesNo
Tell me about it
Notary fees are charged at $15 per notarization when applicable.
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Individual
$795.00

Individual & Estate
$895.00

Total

$0.00

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Conservatorship Intake Form

Character and estimated value of the property of the estate:

Proposed Conservatee Information

List of Conservatee's Relatives:

PERSONAL NEEDS

Medication Details

Activities

Special Problems

FINANCIAL NEEDS

Monthly Income

Monthly Expenses

Insurance

LIving Expenses

Additional Monthly Expenses

If monthly expenses exceed monthly income, how do you plan to meet the shortfall?