{"data":{"id":"us-ri/r.i.-gen.-laws-33-15-47","jurisdiction":"us-ri","citation":"R.I. Gen. Laws § 33-15-47","heading":"Forms.","body":"The following forms shall be used for the purposes of this chapter:\nSTATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF ______ _________________________________________ No. _________________________________________ ESTATE OF _________________________________________ PERSONAL ESTATE ESTIMATED AT $_______________ CITY/TOWN OF ____________ 20__________\n_______________________________________ 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 _________________________________________ .\nBased 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:\n____\thealth care\n____\tfinancial matters\n____\tresidence\n____\tassociation\n____\tother\nRegarding each area indicated, please describe the specific assistance needed:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nIndicate 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 ____ Supported Decision-Making, see chapter 66.13 of title 42 ____ Other\nPlease describe the basis for the determination that the alternative will not meet the needs of the respondent for each alternative explored and deemed inappropriate:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n□\tNo conflict of interest that would interfere with guardianship\n\tduties.\n□\tNo criminal background that would interfere with guardian-\n\tship duties.\n□\tThe capacity to manage financial resources involved.\n□\tThe ability to meet requirements of law and unique needs of\n\tindividual.\n□\tDemonstrated willingness to undergo training.\n\t_________________________________________\n\tSignature\n\t_________________________________________\n\tName\n\t_________________________________________\n\tAddress\n\t_________________________________________\n\tTelephone\nSubscribed and sworn to before me as to the truth of the above facts by ____ in ____ on the ____ day of ____ , 20__ .\n\t_________________________________________\n\tNotary Public\n\t_________________________________________\n\tPrint Name\n\t_________________________________________\t\t_________________________________________\n\tDated\t\tPROBATE JUDGE\nThis notice should be served at once and returned to the clerk of the court.\nNOTICE\nSTATE OF RHODE ISLAND\nBY THE PROBATE COURT OF THE ______ OF ______\nBY THE COUNTY OF _______________________________________ AND STATE AFORESAID\nTo _______________________________________\nEstate or _______________________________________\nDocket No. _______________________________________\nA petition for Limited Guardianship/Guardianship has been filed in the Probate Court of the city/town of _______________________________________ .\n_________________________________________ has requested that the Probate Court appoint\nPetitioner\nA hearing regarding this Petition shall be held\ndate\ntime\n_________________________________________\nThe Petition requests that the Probate Court consider the qualification of the following individual/agency to serve as your limited guardian/guardian:\nA guardian ad litem will be appointed by the Probate Court to visit you, explain the process and inform you of your rights.\nYou 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.\nIf 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:\nYour health care; your money; where you live; and with whom you associate.\nCopies of this Notice will be mailed to:\nI certify that I hand-delivered and read this Notice to _______________________________________ on the ___________ day of _____________________ , 20___________ .\n\t_________________________________________\n\tSignature\n\t_________________________________________\n\tPrint Name\n\t_________________________________________\n\tAddress\nI 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___________ .\n\t_________________________________________\n\tSignature\n\t_________________________________________\n\tPrint Name\n\t_________________________________________\n\tAddress\nSubscribed and sworn to before me this ___________ day of _____________________ , 20___________ .\n\t_________________________________________\n\tNotary Public\nJudge of the Probate Court of the _______________________________________ of _______________________________________ this ___________ day of _____________________ , 20___________ .\n\t_________________________________________\n\tClerk\nName of Individual being assessed: Current Address:\n_______________________________________\t\t_________________________________________\n\t\t_________________________________________\nDate of Birth:\t\tPermanent Address (if different):\n_______________________________________\t\t_________________________________________\n\t\t_________________________________________\nThis 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.\nThis document has two parts. Please first complete the part which is right after these instructions, titled Assessment. Then complete the second section, titled Summary.\nTo 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.\nTo 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.\nThe document must be signed and dated by the person completing it. It does not need to be notarized.\nTHE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON\n____________\n(DATE)\n1. DIAGNOSIS and PROGNOSIS:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n2. MEDICATION (PLEASE LIST):\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nHow do the above medications, if any, affect the individual’s decision-making ability? Please explain:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n3. CURRENT NUTRITIONAL STATUS:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(A) Intact; (B) Mild Impairment; (C) Moderate Impairment; (D) Severe Impairment\n(A) Intact; (B) Mild Impairment; (C) Shifting/Wandering; (D) Delirium; (E) Unresponsive\n(A) Intact; (B) Able to Make Most Decisions; (C) Impaired; (D) Gross Impairment\n(A) Intact (B) Sensory Deficits (Hearing/Speech/Sight)\n(C) Impairment In Comprehension/Speech: Mild/Moderate/Severe\n(D) Completely Unresponsive\n(A) ANXIETY/DEPRESSION: (1) None (2) History of Anxiety/Depression\n(3) Moderate Symptoms of Anxiety/Depression\n(4) Severe symptoms with sleep/appetite/energy disturbance\n(5) Suicide/Homicidal\n(B) OTHER: (1) Suspiciousness/Belligerence/Explosiveness\n(2) Delusions/Hallucinations (3) Unresponsive\nIf 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:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(A) Intact/Exercises (B) Drives Car Or Uses Public Transportation\n(C) Independent Ambulation in Home Only; (D) Walker/Cane; (E) Requires Assistance\nIf you circled (C), (D), or (E), is situation treatable or reversible? If so, how?\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(A) No Assistance Needed;\n(B) Requires Assistance with (1) Meals (2) Bathing (3) Dressing (4) Toileting/Feeding\nIf you circled any of (B), is individual aware that assistance is required? _________________________________________\nIs individual willing to accept assistance? _________________________________________\nIs individual able to arrange for assistance? _________________________________________\n(A) No Active Problem; (B) Initiates Problem Identification; (C) Actively Cooperative; (D) Passively Cooperative; (E) Passively Uncooperative; (F) Actively Uncooperative\n(CIRCLE ONE IN (A) AND ONE IN (B))\n(A) SUPPORT:\n(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\n(B) SOCIAL SKILLS:\n(1) Very Good Social Skills; (2) Good Social Skills; (3) Interacts With Prompting; (4) Isolated\nI hereby certify that I have reviewed sections A, B, \u0026 C attached hereto and based on such assessments that the individual’s decision-making ability is as follows:\n(1) PLEASE DESCRIBE AS FULLY AS YOU CAN THE INDIVIDUAL’S DECISION-MAKING ABILITY IN EACH OF THE FOLLOWING AREAS:\nA. FINANCIAL MATTERS\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nB. HEALTH CARE MATTERS\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nC. RELATIONSHIPS\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nD. RESIDENTIAL MATTERS\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(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.)\n(1) FINANCIAL MATTERS Yes No Limited\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(2) HEALTH CARE MATTERS Yes No Limited\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(3) RELATIONSHIPS Yes No Limited\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(4) RESIDENTIAL MATTERS Yes No Limited\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n(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.\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n\t_________________________________________\n\tSignature\n\t_________________________________________\n\tName (Print or Type)\n\t_________________________________________\n\tTitle\n\t_________________________________________\n\tDate\nNames and titles of others who assisted in Preparation of This Assessment.\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nSTATE OF RHODE ISLAND\tPROBATE COURT OF THE\nCOUNTY OF _______\nEstate of _________________________________________\tDocket No. _________________________________________\n(1) The residence of the ward is _________________________________________\n(2) The medical condition of the ward is:\n_________________________________________\n_________________________________________\n_________________________________________\n(3) I perceive the following changes in the decision making capacity of the ward:\n_________________________________________\n_________________________________________\n_________________________________________\n(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:\n_________________________________________\n_________________________________________\n_________________________________________\n(If more space is needed, please attach a supplement).\n_________________________________________ Guardian _________________________________________ Date STATE OF RHODE ISLAND PROBATE COURT OF COUNTY OF THE _________________________________________ (Estate Name) _______ Probate Court No. ___________\nNow 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:\n* The nature, purpose, and legal effect of the appointment of a guardian;\n* 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;\n* The name of the person known to be seeking appointment as guardian:\nBased 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.\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nBased 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:\nRegarding whether the respondent is in need of a guardian of the type prayed for in the petition:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\nRegarding 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:\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n_________________________________________\n\t\tRespectfully submitted,\nDate: _________________________________________\t\t_________________________________________\n\t\t(Name of Guardian Ad Litem)","path":["Title 33 Probate Practice and Procedure","Chapter 15 Limited Guardianship and Guardianship of Adults"],"source_url":"https://webserver.rilegislature.gov/Statutes/TITLE33/33-15/33-15-47.htm","current_through":"site files published 2025-08-13","vintage":"","retrieved_at":"2026-09-05T19:58:37Z","sha256":"725155bd289de1e8d4f86fab1d629e0f5a8f1b15fefdda6cea86c4ca4f318c6f","source_id":"us-ri","stale":true,"prev":"us-ri/r.i.-gen.-laws-33-15-46","next":"us-ri/r.i.-gen.-laws-33-15.1-1"},"notice":"GroundRules: Original legal text. Not legal advice."}