Full Name of Party Filing this Document

Mailing Address (Street or Post Office Box)

City, State, and Zip Code

Telephone Number

Email Address (if any)

IN THE DISTRICT COURT OF THE 	JUDICIAL DISTRICT OF THE STATE OF IDAHO, IN AND FOR THE COUNTY OF 	

IN THE MATTER OF THE GUARDIANSHIP OF

an Adult. a Minor.	Case No. 	 Proposed Guardianship Care Plan	

Instructions.

This report must provide the court with a complete picture of your proposed plans for the person for whom you petitioned or the person under guardianship in the next year.

Sometimes the information for the care plan can be included in the petition you file to become a guardian. Check with the court about your need to file this care plan.

As a guardian you will also be required to file status reports:
The first status report is due within 30 days after the anniversary date of your appointment.
A status report is due every following year within 30 days after the anniversary date of your appointment.
A final status report is due within 30 days after the resignation, removal, or termination of the appointment unless the judge orders otherwise.
Please type or print clearly using black ink.
After completing this report, you must sign it under penalty of perjury.
File with the clerk of the court, provide copies to individuals as ordered by the court, and keep a copy for your records.

SECTION I – Answer the following questions about the person for whom you petitioned or the person under guardianship (Referred to as “Person” below).

Name: 	
Physical address: 	

Contact number(s): Residence: 			 Cell: 		Work: 	 Fax: 		Email: 	 Type of residence:
Proposed Guardian’s Home	 Own Home	Rental Certified Family Home/Group Home	Intermediate Care Facility Temporary Medical Facility	 Assisted Living or Nursing home
Relative’s home; describe relationship: 	 Other: 	
Is the residence expected to change in the next 12 months? Yes	 No	 Unknown
If yes, explain why: 	

What is your relationship to the Person? 	

List other individuals living in the household and their relationship to the Person and each other: (Write “N/A” if living in a hospital, medical facility, assisted living, or nursing home): 	

Has a conservator also been appointed? Yes	 No
Name of conservator: 	 Address: 	 Phone number: 	
List the individuals you consulted with in preparation of this care plan: (including family members, friend(s), care and medical providers, case managers, attorney(s), service providers, Guardian ad Litem) 	

Describe the information or opinion provided to you by the individuals listed above (attach any document, reports, or information you were provided): 	

Have you considered alternatives to guardianship (supported decision-making, powers of attorney)?  Yes	 No
If no, why not? 	

Describe any efforts you made to encourage and support decision-making by the Person:

SECTION II – Services.
(Services may include outpatient treatment, treatment plans, therapy, rehabilitation, social, counseling, person centered plan, etc.)

Describe any current or past wishes or instructions made by the Person, regarding services:

Describe any services the Person currently receives: 	

Describe any proposed changes to services in the next year: 	

Would the Person benefit from any additional services or assistance with decision-making?  Yes	 No	 Unknown
Please explain: 	

SECTION III – Medical (attach any records, reports, or documentation).
Describe any current or past wishes or instructions made by the Person, regarding medical services: 	

Does the Person have any of the following?
Medical powers of attorney	Living Will	POST/DNR/DNI
Describe the Person’s physical health:
 Poor	 Fair	 Good	 Excellent
If poor or fair, please explain: 	

Describe the Person’s mental health:
 Poor	 Fair	 Good	 Excellent
If poor or fair, please explain: 	

Describe any medical and/or mental health treatment the Person may receive in the next 12 months: 	

Would the Person benefit from any additional medical and/or mental health services?  Yes	 No	 Unknown
Please explain: 	

SECTION IV - Employment, Education, and Training.
Describe any current or past wishes or instructions made by the Person, regarding employment, education, and training: 	

Is the Person employed or involved in any educational or training programs?  Yes	 No
Please explain: 	

Describe any proposed or anticipated changes in employment, education, and training in the next 12 months: 	

SECTION V - Social And Cultural Activities (attach any records, reports, or documentation).
Describe any current or past wishes or instructions made by the Person, regarding social and cultural activities: 	

Describe the Person’s relationships and activities with friends, family, boyfriend, girlfriend, and community: 	

Describe activities the Person is currently involved in, including hobbies, clubs, affiliations, volunteering, religious activities: 	

Describe any proposed or anticipated changes to these activities: 	

Describe any online/social media activities by the Person (Facebook, LinkedIn, e-mail accounts, Twitter, Instagram, etc.): 	

Describe any concerns related to the Person’s social and cultural activities/relationships:

CERTIFICATION UNDER PENALTY OF PERJURY

I certify under penalty of perjury pursuant to the law of the State of Idaho that the foregoing is true and correct.

Date Submitted: 	

Proposed Guardian/Guardian’s Signature

Typed/Printed Name

Street or Post Office Address

City, State and Zip Code

Telephone Number(s)

Fax Number

Email

CERTIFICATE OF SERVICE

I certify that on (date) 	I served a copy to: (name all parties in the case other than yourself)

Person under proposed guardianship

(Name)

(Street or Post Office Address) (City, State, and Zip Code)

Attorney or Guardian ad Litem

(Name)

(Street or Post Office Address) (City, State, and Zip Code)

(Name)

(Street or Post Office Address) (City, State, and Zip Code)

(Name)

(Street or Post Office Address) (City, State, and Zip Code)

(Name)

(Street or Post Office Address) (City, State, and Zip Code)		
By e-mail: 	 By mail
By fax (number): 	
By personal delivery

By e-mail: 	 By mail
By fax (number): 	
By personal delivery

By e-mail: 	 By mail
By fax (number): 	
By personal delivery

By e-mail: 	 By mail
By fax (number): 	
By personal delivery

By e-mail: 	 By mail
By fax (number): 	
By personal delivery	
Typed/Printed Name		Guardian’s Signature