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Undue Influence: Definitions and Applications - California Courts ...

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Borchard grant file review<br />

20. Does the proposed conservatee have involved family members?<br />

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Yes<br />

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No<br />

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Unable to determine<br />

21. Impairments<br />

None Mild Moderate Severe<br />

Hearing nmlkj nmlkj nmlkj nmlkj<br />

Vision nmlkj nmlkj nmlkj nmlkj<br />

Mobility nmlkj nmlkj nmlkj nmlkj<br />

Cognition nmlkj nmlkj nmlkj nmlkj<br />

Speech nmlkj nmlkj nmlkj nmlkj<br />

Substance abuse nmlkj nmlkj nmlkj nmlkj<br />

Mental health issues nmlkj nmlkj nmlkj nmlkj<br />

Continence nmlkj nmlkj nmlkj nmlkj<br />

ADLs nmlkj nmlkj nmlkj nmlkj<br />

Executive functioning nmlkj nmlkj nmlkj nmlkj<br />

Depression nmlkj nmlkj nmlkj nmlkj<br />

Anxiety nmlkj nmlkj nmlkj nmlkj<br />

Diminished mental<br />

capacity<br />

nmlkj nmlkj nmlkj nmlkj<br />

Other nmlkj nmlkj nmlkj nmlkj<br />

Further describe impairments<br />

22. Other traits of proposed conservatee (Check all that apply)<br />

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Suffered recent loss<br />

gfedc<br />

Seeks attention<br />

gfedc<br />

Experiencing a life transition<br />

gfedc<br />

Poor judgment<br />

gfedc<br />

Sleep deprived<br />

gfedc<br />

Lack of insight<br />

gfedc<br />

Under effects of medications<br />

gfedc<br />

Dependent personality<br />

gfedc<br />

Lonely<br />

gfedc<br />

Acquiescence<br />

gfedc<br />

Other (please specify)<br />

3. Characteristics of Alleged Abuser<br />

23. Single abuser or multiple abusers?<br />

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nmlkj<br />

Single<br />

Multiple<br />

24. Age (Leave blank if unknown)<br />

Abuser #1<br />

Abuser #2<br />

144<br />

Page 5

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