CONSERVATORSHIP OF THE 

PERSON

ESTATE OF (Name):

CASE NUMBER:

GC-335A

CONSERVATEE

PROPOSED CONSERVATEE

ATTACHMENT TO FORM GC-335, CAPACITY DECLARATION—CONSERVATORSHIP,  
ONLY FOR (PROPOSED) CONSERVATEE WITH A MAJOR NEUROCOGNITIVE DISORDER

9.  It is my opinion that the (proposed) conservatee                                                                       a major neurocognitive disorder (such 

does NOT have

HAS

as dementia) as defined in the current edition of Diagnostic and Statistical Manual of Mental Disorders.

a.

Placement of (proposed) conservatee. (If the (proposed) conservatee requires placement in a secured-perimeter 
residential care facility for the elderly, please complete items 9a(1)–9a(5).)

(1)

The (proposed) conservatee needs or would benefit from placement in a restricted and secure facility because (state 
reasons; continue on Attachment 9a(1) if necessary):

(2)

The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of form GC-335, include 
(describe; continue on Attachment 9b(2) if necessary):

(3)
(4)

The (proposed) conservatee HAS the capacity to give informed consent to this placement.
The (proposed) conservatee does NOT have the capacity to give informed consent to this placement. The deficits in 
mental function assessed in item 6 of form GC-335 and described in item 9a(2) above significantly impair the 
(proposed) conservatee's ability to understand and appreciate the consequences of giving consent to placement in a 
restricted and secure environment.

(5)

is NOT
A locked or secured-perimeter facility                                                    the least restrictive environment appropriate to the 
needs of the (proposed) conservatee.

is

b.

Administration of medications. (If the (proposed) conservatee requires administration of medications appropriate to the 
care and treatment of major neurocognitive disorders (including dementia), please complete items 9b(1)–9b(5).)

(1)

For the reasons stated in item 9b(5), the (proposed) conservatee needs or would benefit from the following medications 
appropriate to the care and treatment of major neurocognitive disorders (including dementia) (list medications; continue on 
Attachment 9b(1) if necessary):

(2)

The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of from GC-335, include 
(describe; continue on Attachment 9b(2) if necessary):

(3)

(4)

(5)

The (proposed) conservatee HAS the capacity to give informed consent to the administration of medications 
appropriate to the care and treatment of major neurocognitive disorders (including dementia).
The (proposed) conservatee does NOT have the capacity to give informed consent to the administration of 
medications appropriate to the care and treatment of major neurocognitive disorders (including dementia). The 
deficits in mental function assessed in item 6 of form GC-335 and described in item 9b(2) above significantly impair 
the (proposed) conservatee's ability to understand and appreciate the consequences of giving consent to the 
administration of medications for the care and treatment of major neurocognitive disorders (including dementia).
The (proposed) conservatee needs or would benefit from the administration of the medications listed in item 9b(1) because 
(discuss reasons; continue on Attachment 9b(5) if necessary):

10. Number of pages attached:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:

(TYPE OR PRINT NAME)

Form Adopted for Mandatory Use 
Judicial Council of California 
GC-335A [Rev. January 1, 2019]

MAJOR NEUROCOGNITIVE DISORDER ATTACHMENT  
TO CAPACITY DECLARATION—CONSERVATORSHIP

(SIGNATURE OF DECLARANT)

Page 1 of 1

Probate Code, §§ 811, 2356.5 
www.courts.ca.gov