CONSERVATOR'S REPORT PC-371 REV. 10/07
STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):
COURT OF PROBATE [Type or print in black ink.] [Use back of form or additional sheets if more space is required.] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO.
IN THE MATTER OF [Name, address, zip code, and date of birth] PRESENT ADDRESS OF CONSERVED PERSON [If institutionalized, give name and address of institution.]
HEREINAFTER REFERRED TO AS THE "CONSERVED PERSON."
PRESENT TREATING PHYSICIAN [Name, address, and zip code]
CONSERVATOR OF THE PERSON [Name, address, zip code, and telephone number]
This conservator's report is being filed for the following reason: [C.G.S. §§45a-654(f), 45a-656, 45a-660(c)] Annual Report Court-ordered Report Significant change in the conserved person's capacity to meet the essential requirements for health or safety Reporting period covered by this report --- FROM: Conservator has resigned or has been removed. Application for restoration has been filed. Temporary conservatorship has terminated. Other: TO:
Indicate number of visits made during reporting period: Describe the changes, if any, to the mental, emotional, or physical condition of the conserved person during the reporting period. [Be specific.]
If applicable, list any significant actions you have taken regarding the conserved person during this reporting period.
If applicable, list any significant problems relating to the conservatorship that have arisen during this reporting period.
Provide a statement indicating whether the appointment of a conservator continues to be the least restrictive means of intervention for managing the conserved person's needs.
Describe the efforts made during the reporting period to encourage the independence of the conserved person.
This section is to be completed for reviews of conservatorship pursuant to C.G.S. §45a-660. continued modified terminated. In my opinion, the conservatorship should be Give reasons for your answer.
Dated at:
,Connecticut, on [Month, Day, Year] ....................................................................................... Conservator:
CONSERVATOR'S REPORT PC-371
RESET