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PETITION FOR APPOINTMENT OF [Docket No. | CommonweaihofMassachaatis
GUARDIAN FOR AN yoaie Probe se |
INCAPACITATED PERSON I%60 U7. US
In the Interests of:
| Vasha Camilia Thomas _ MORE. OLB. Division
First Name, ~ —“Widddle Name; Tast Name
(Alleged incapacitated Person/Respondent:
the Incapacitated Person and
The Court shall encourage the development of maximum self-reliance and jndependence of
‘make appointive and other orders:only to'the extent necessitated by the Incapacitated. Person's.limitations.or otter conditions:
warranting the procedure,
1. Information about the Respondent:
z v Thomas
Name: Vasha Thomas
CG.
FirstName. he, ft MT _
st Nain (steer, Ny wy
* Arabic, Manabi 2 Primary Phone # unknown
Primary. Language: [Xf English Dd Other: ]
Date of Birth: 5:16.1999 Age: _22 Gender: Fernale: _
Principal Residence: ___ 24 Wellesley College Rd Unit 7022 Wellesi MA _ 02481-0270
ress) TARE Unig. Novetey: ~~ City Town) — “Statey ip
Date Residence was established: September 2017.
‘Current Address: [X] Same'as Above-or []'he following address:
ess) Te No. ety rrown), ___—~" 7statey ~~ Tap
tf this appointment is made;, Respondent will reside:at [_].Principal Residence [] Current Address XJ the following address:
Gani Wey Sinnies Way. Buford GA. 30519
4 3 , “Apt, Unit, No: etc. City/Town) (Statey Sip
Respondent ["]is &l is not. alleged intellectually. disabled. .
2. information about the Petitioner: .
Name: Valeria E Thomas
, First Name, > TE Tas Name,
1972 Binnies Wa Buford : GA 30519
Tess) "TARE, Unit; No. ete (CityrTowny “(Staley Cipy
Primary Phone #: (919) 601-2863 Relationship to Respondent: Mother
E-mail: 3gibsonthomaskids@gmall.com
State your interest in:the appointment:
I wish to advocate for mental health and medical care Issues, namely, severe depression, self-harm, PTSD, suicidal
Ideations; and medication regulation, including evaluation, testing and treatment for possible traumatic brain disorder:
resulting from 2 severe concussions. | will'also have her evaluated for Asperger's support from a qualified professional.
_() Aniattachriiont to this petition provides Information on co-patitioner(s). —
_ The Petitioner is requesting:
beappointed —_[_] that some suitable persori bé appointed (1 that the person named below be’appointed:Name: Valeria E. Thomas:
FirstName . MIT tastName
1972 Binnies Way Buford GA 30519
~ ~~ (Address) (Apt, Unit; No. ete;): oe (City/Town) Ctatey— este
Primary Phone #: (919) 601-2863 Relationship to Respondent: Mottier:
E-mail: 3gibsonthomaskids@gmail.com
Name: Angela R. ___ Burroughs
- FirstName WT _ Test Name
4 Thorton Court Durham NC 27703.
ress) pt Unt (City/Town), Giate) (py
Primary Phone #: (919) 621-1911
E-mail: ABurroughs@E! thosExcel.com a
An attachment to this petition provides information on co-Guardian(s):
ship to Respondent: _ godmother
4 Heorshe has priority of appointment because the riominee is:(choose one):
(Nominated in.a-durable power of attorney by Respondent: [x] Respondent's parent or a parental nominee; OR
[1] Respondent's spouse or a:spousal nominee: [1] None of the:above.
State the reason the proposed guardian(s) should be appointed:
As mother of Respondent, | am intimately acquainted with her needs related to mental health, therapy,
imedications, Asperger's, nutrition.and medical issues; Having her best interest in mind with the end result of her
being independent; | will advocate in the areas, above, as well as'for hef completion of the few classes needed to
graduate from Wellesley. College. She-is unstable, not making sound decision right now, and she needs advocacy.
5. Thists a Petition for appointment:of a (choose one):
@ Limited Guardian, State the powers being-sought:
[1 to apply for health insurance benefits including MassHealth on. behalf of Respondent;
fq te obtain copies:of statements or any other-records from banks, insurance. companies, or other financial
institutions verifying balances and {transactions of accolitits stariding in the name: of the incapacitated Person,
individually, of jointly with another. . .
Bother
*mental health care:and medication monitoring “evaluation and treatment for traumatic brain injury “if
necessaty, feadmigsion to mental café unit/hospital “academic planning “travel with her to our home for care.
OR
O General Guardian. State the reasons why’a Limited. Guardianship is inappropriate:
6. .A Medical Certificate dated with an éxamination having taken place’ within 30 days of the filing of the petition or, if
Respondent Is alleged to be intellectually disabled, a Clinical Taam: Report dated with-an.examination having taken
place. within 180 daye ofthe filing of the petition: .
‘EE Is:fited'with this Petition or is on fle with the Court (Dacket No.
Bd. filed with this Petition and is not.on file with this Court:
if'a Medical Certificate or Clinical Team Report is not filed with this Petition; or on:file with this Court, you rust immediately
--file'and present.a motion requesting that the Court permit it to be filed late or waive the filing requirement. An.affidavit must.
ymhpany the mation explaining why it is impossible to file'a Medical Certificate or Clinical Team Report with this Petition.
__):0R
guardianship te necessary Is detalled in'the most recent Medical Certificate or Clinical Team Report.
this petition orls described as follows:. ... : rece ‘” “ ° a piaRespondent is a danger t
[ self and, is unable to. make:sound decisions for her care. She needs:assistance with
ADLs and treatmentimedication compliance, and advocacy. As her mother, her best interest is my priority. :
8, The:nature and extent of Respondent's alleged incapacity is detailed in the Medical Certificate or Clinical Team
Report filed with this petition or is described as follows: .
She is a danger'to herself, suicidal, depressed, self-harms and abuses medications. 6/4/21 admission to Newton-
Wellesley on the psych unit; Aug 2020'in the psych unit in CA for suicide attempt; possibile traumatic. brain injury.F. Heath Care Agent .
Agent;
mio Ho pos ett none lt he apparnt or presume . ore
© ‘Curent Consertorin be Conmanwesh or sents aaa T Thdicate this |
PP ame Primary Addons, | Primary Phone (Chek a tay person is
Cc i [1 Spouse [1 Representative Payee [1 Minor
. Ccnie Heath Cae ron Incompetent
[1] Guardian [7] Durable Power Holder j
Nei. Tomas een (919)604-2863 [Xj Nominated Guardian [) Had care. & custody inthe last
Hall 1] Conservator 60 days.
(Relate: —_{—
: Spouse ([] Representative Payee L Minor
Ey chia [1 Health Care: Proxy {X Incompetent
1 Guardian [7] Durable Power Holder
Angela R. Burroughs Hang Cats Gatetst4 Nominaed Guardian [] Had care-& custody in thelast
[1 Conservator 80. days,
KX Relative: godmather
=
[1 Spouse a Represetave Payee - 0 Hinor
(child [7] Health Care Proxy [7 Incompetent
(0 Guardian 1] Durable Power Holder
C1 Nominated Guardian [7] Had cate & custody in the last
[] Conservator 60 days,
[7] Relative
raTabonstpl , InformationlExplatiation;
Res have, lai ityes,a copy ofthe |(W'a Petition has been filed but not
elsewhere: documentis: | allowed, please list Court and
Docket Number of pending case)
ae | C1 Yes nd te pros infomation itd at 9 [tached
‘curent Guardian? |
No (Unavailable
1 Uncertain
| i [1] Yes and the person's inkrmatin itd at 9 [1 Atached
JAdocument nominating a Guardian? Rito [Unavailable
[7] Uncertain
1 Yesiandlthe person's information is sted at 9 [1] Attached
JAcurent Conservator? ry (J) Unavailable
[1] Unoertain
a [7 Yesand the persons information is sted at 9 [Catch
Representative Payee? No [Unavailable
(1 Uncertain
oi {LJ Yes andthe persons infration i listed! at 0.9 [Attached = hasnever had. an
Atel Care ent? | Agent, and | do not believe she
‘a Ag [No [] Unavailable | has one now. However, itis
s Bl Uncertain possible, but highly unlikely:
a Dy £1] Yes and the person's informations ited at 9 [7 Attached Lengpartie nde
BIA Durable Power of Attomey/Agent? r mn OA, and | do not believe she has
[No [Unavailable ——_| one now: However, tis possible,
1 Uncertain but highly unbkely.44. Respondent [] has [X] has not executed a MOLST (Medical Orders for Lifé-Sustaining Treatment).
12. Respondent [is [XJis not entitled to benefits from the Departrrient of Veterans Affairs or (1 uncertain.
43. Does Respondent have any assets, e:9. bank accounts, property? [XJ Yes: FJ No [J Uncertain. If Yes, identity:
‘Description of: Assets e, Q- Bank Accounts, Property, Insurance, Pensions Estimated Value.of Property
DO NOT INCLUDE NAMES OF INSTITUTIONS OR. ACCOUNT NUMBERS. -
Bank Account: (unknown amount)
Bank Account: | $0.30
Total | $0.30
(1 An attachment to this petition provides additional information,
14. Does:Resporident have any anticipated income? [1 Yes [J No &X] Unceitain. If Yes, identify:
Description of Income; e.g. Social Security, Interest Amount of Anticipated Monthly
DO:NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS Income or Receipts
Total
[ An attactiment to this Petition provides, additional.information.
15; [XJ Petitioner seeks specific Court auithorization:
1 to.admitRespondentto:a:nursing facility:
{XJ to treat ‘Respondent with antipsychotic: medication in accordance with a treatment plan;
1 for the following treatment or action for which a, substituted judgment determination may be required:
“testing, evaluation and treatment fora traumatic brain injury’ j, admission into‘an.appropriate
‘mental health or medical care unit “care monitoring “advocacy for mental health and medical care needs.
EX to revoke the Health Caré-Proxy of Respondent.
"WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:
Appoint [59 Petitioner
oO
“FirstName aT
ED Some suitable person.
TastName
ag Biimited guardian(s) [[] general guardian(s) of Respondent, with any specific’authorization as may ba requested in
paragraph 15 above.
view -rHOmAs Ph leo{Petitioner requests the Court waive sureties on the Bond for the:fallowing reasons:
[The Respondent has minimal. fun
Respondent.
[JA Conservator is appointed of is being requested.
Other:
This Is a petition for temporary guardianship and does not require surety bond.
ds.to be thanaged and requiring suitéties would place a financial burden on the
In.addition, Pétitioner requests. that the Court:
allow Petitionerto.determine, with guidance:from méntal health and medical professionals providing care to
Respondent, ifshe should remain in MA for care or move home with Petitioner/Guardian for continuous care.
SIGNED UNDER THE PENALTIES OF PERJURY
\ affirm or swear under oath that havé tead the foregoing Petition and that the-statements set forth therein: are true: and correct
the best of my knowledge. }
Date: _.__ dune 11, 2021
Date:
Signature of Co-petitioner (if applicable)
{ assent.to the foregoing Petition:
Print\Name . Signature
Attomey for Petitioner
Signature of Attorney
Print narey
TeyiTowny - Ea 257 —
PrimaryPhome;
B.B.0. #
E-mail:
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PETITION FOR APPOINTMENT OF [Docket No. | CommonweaihofMassachaatis GUARDIAN FOR AN yoaie Probe se | INCAPACITATED PERSON I%60 U7. US In the Interests of: | Vasha Camilia Thomas _ MORE. OLB. Division First Name, ~ —“Widddle Name; Tast Name (Alleged incapacitated Person/Respondent: the Incapacitated Person and The Court shall encourage the development of maximum self-reliance and jndependence of ‘make appointive and other orders:only to'the extent necessitated by the Incapacitated. Person's.limitations.or otter conditions: warranting the procedure, 1. Information about the Respondent: z v Thomas Name: Vasha Thomas CG. FirstName. he, ft MT _ st Nain (steer, Ny wy * Arabic, Manabi 2 Primary Phone # unknown Primary. Language: [Xf English Dd Other: ] Date of Birth: 5:16.1999 Age: _22 Gender: Fernale: _ Principal Residence: ___ 24 Wellesley College Rd Unit 7022 Wellesi MA _ 02481-0270 ress) TARE Unig. Novetey: ~~ City Town) — “Statey ip Date Residence was established: September 2017. ‘Current Address: [X] Same'as Above-or []'he following address: ess) Te No. ety rrown), ___—~" 7statey ~~ Tap tf this appointment is made;, Respondent will reside:at [_].Principal Residence [] Current Address XJ the following address: Gani Wey Sinnies Way. Buford GA. 30519 4 3 , “Apt, Unit, No: etc. City/Town) (Statey Sip Respondent ["]is &l is not. alleged intellectually. disabled. . 2. information about the Petitioner: . Name: Valeria E Thomas , First Name, > TE Tas Name, 1972 Binnies Wa Buford : GA 30519 Tess) "TARE, Unit; No. ete (CityrTowny “(Staley Cipy Primary Phone #: (919) 601-2863 Relationship to Respondent: Mother E-mail: 3gibsonthomaskids@gmall.com State your interest in:the appointment: I wish to advocate for mental health and medical care Issues, namely, severe depression, self-harm, PTSD, suicidal Ideations; and medication regulation, including evaluation, testing and treatment for possible traumatic brain disorder: resulting from 2 severe concussions. | will'also have her evaluated for Asperger's support from a qualified professional. _() Aniattachriiont to this petition provides Information on co-patitioner(s). — _ The Petitioner is requesting: beappointed —_[_] that some suitable persori bé appointed (1 that the person named below be’appointed:Name: Valeria E. Thomas: FirstName . MIT tastName 1972 Binnies Way Buford GA 30519 ~ ~~ (Address) (Apt, Unit; No. ete;): oe (City/Town) Ctatey— este Primary Phone #: (919) 601-2863 Relationship to Respondent: Mottier: E-mail: 3gibsonthomaskids@gmail.com Name: Angela R. ___ Burroughs - FirstName WT _ Test Name 4 Thorton Court Durham NC 27703. ress) pt Unt (City/Town), Giate) (py Primary Phone #: (919) 621-1911 E-mail: ABurroughs@E! thosExcel.com a An attachment to this petition provides information on co-Guardian(s): ship to Respondent: _ godmother 4 Heorshe has priority of appointment because the riominee is:(choose one): (Nominated in.a-durable power of attorney by Respondent: [x] Respondent's parent or a parental nominee; OR [1] Respondent's spouse or a:spousal nominee: [1] None of the:above. State the reason the proposed guardian(s) should be appointed: As mother of Respondent, | am intimately acquainted with her needs related to mental health, therapy, imedications, Asperger's, nutrition.and medical issues; Having her best interest in mind with the end result of her being independent; | will advocate in the areas, above, as well as'for hef completion of the few classes needed to graduate from Wellesley. College. She-is unstable, not making sound decision right now, and she needs advocacy. 5. Thists a Petition for appointment:of a (choose one): @ Limited Guardian, State the powers being-sought: [1 to apply for health insurance benefits including MassHealth on. behalf of Respondent; fq te obtain copies:of statements or any other-records from banks, insurance. companies, or other financial institutions verifying balances and {transactions of accolitits stariding in the name: of the incapacitated Person, individually, of jointly with another. . . Bother *mental health care:and medication monitoring “evaluation and treatment for traumatic brain injury “if necessaty, feadmigsion to mental café unit/hospital “academic planning “travel with her to our home for care. OR O General Guardian. State the reasons why’a Limited. Guardianship is inappropriate: 6. .A Medical Certificate dated with an éxamination having taken place’ within 30 days of the filing of the petition or, if Respondent Is alleged to be intellectually disabled, a Clinical Taam: Report dated with-an.examination having taken place. within 180 daye ofthe filing of the petition: . ‘EE Is:fited'with this Petition or is on fle with the Court (Dacket No. Bd. filed with this Petition and is not.on file with this Court: if'a Medical Certificate or Clinical Team Report is not filed with this Petition; or on:file with this Court, you rust immediately --file'and present.a motion requesting that the Court permit it to be filed late or waive the filing requirement. An.affidavit must. ymhpany the mation explaining why it is impossible to file'a Medical Certificate or Clinical Team Report with this Petition. __):0R guardianship te necessary Is detalled in'the most recent Medical Certificate or Clinical Team Report. this petition orls described as follows:. ... : rece ‘” “ ° a piaRespondent is a danger t [ self and, is unable to. make:sound decisions for her care. She needs:assistance with ADLs and treatmentimedication compliance, and advocacy. As her mother, her best interest is my priority. : 8, The:nature and extent of Respondent's alleged incapacity is detailed in the Medical Certificate or Clinical Team Report filed with this petition or is described as follows: . She is a danger'to herself, suicidal, depressed, self-harms and abuses medications. 6/4/21 admission to Newton- Wellesley on the psych unit; Aug 2020'in the psych unit in CA for suicide attempt; possibile traumatic. brain injury.F. Heath Care Agent . Agent; mio Ho pos ett none lt he apparnt or presume . ore © ‘Curent Consertorin be Conmanwesh or sents aaa T Thdicate this | PP ame Primary Addons, | Primary Phone (Chek a tay person is Cc i [1 Spouse [1 Representative Payee [1 Minor . Ccnie Heath Cae ron Incompetent [1] Guardian [7] Durable Power Holder j Nei. Tomas een (919)604-2863 [Xj Nominated Guardian [) Had care. & custody inthe last Hall 1] Conservator 60 days. (Relate: —_{— : Spouse ([] Representative Payee L Minor Ey chia [1 Health Care: Proxy {X Incompetent 1 Guardian [7] Durable Power Holder Angela R. Burroughs Hang Cats Gatetst4 Nominaed Guardian [] Had care-& custody in thelast [1 Conservator 80. days, KX Relative: godmather = [1 Spouse a Represetave Payee - 0 Hinor (child [7] Health Care Proxy [7 Incompetent (0 Guardian 1] Durable Power Holder C1 Nominated Guardian [7] Had cate & custody in the last [] Conservator 60 days, [7] Relative raTabonstpl , InformationlExplatiation; Res have, lai ityes,a copy ofthe |(W'a Petition has been filed but not elsewhere: documentis: | allowed, please list Court and Docket Number of pending case) ae | C1 Yes nd te pros infomation itd at 9 [tached ‘curent Guardian? | No (Unavailable 1 Uncertain | i [1] Yes and the person's inkrmatin itd at 9 [1 Atached JAdocument nominating a Guardian? Rito [Unavailable [7] Uncertain 1 Yesiandlthe person's information is sted at 9 [1] Attached JAcurent Conservator? ry (J) Unavailable [1] Unoertain a [7 Yesand the persons information is sted at 9 [Catch Representative Payee? No [Unavailable (1 Uncertain oi {LJ Yes andthe persons infration i listed! at 0.9 [Attached = hasnever had. an Atel Care ent? | Agent, and | do not believe she ‘a Ag [No [] Unavailable | has one now. However, itis s Bl Uncertain possible, but highly unlikely: a Dy £1] Yes and the person's informations ited at 9 [7 Attached Lengpartie nde BIA Durable Power of Attomey/Agent? r mn OA, and | do not believe she has [No [Unavailable ——_| one now: However, tis possible, 1 Uncertain but highly unbkely.44. Respondent [] has [X] has not executed a MOLST (Medical Orders for Lifé-Sustaining Treatment). 12. Respondent [is [XJis not entitled to benefits from the Departrrient of Veterans Affairs or (1 uncertain. 43. Does Respondent have any assets, e:9. bank accounts, property? [XJ Yes: FJ No [J Uncertain. If Yes, identity: ‘Description of: Assets e, Q- Bank Accounts, Property, Insurance, Pensions Estimated Value.of Property DO NOT INCLUDE NAMES OF INSTITUTIONS OR. ACCOUNT NUMBERS. - Bank Account: (unknown amount) Bank Account: | $0.30 Total | $0.30 (1 An attachment to this petition provides additional information, 14. Does:Resporident have any anticipated income? [1 Yes [J No &X] Unceitain. If Yes, identify: Description of Income; e.g. Social Security, Interest Amount of Anticipated Monthly DO:NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS Income or Receipts Total [ An attactiment to this Petition provides, additional.information. 15; [XJ Petitioner seeks specific Court auithorization: 1 to.admitRespondentto:a:nursing facility: {XJ to treat ‘Respondent with antipsychotic: medication in accordance with a treatment plan; 1 for the following treatment or action for which a, substituted judgment determination may be required: “testing, evaluation and treatment fora traumatic brain injury’ j, admission into‘an.appropriate ‘mental health or medical care unit “care monitoring “advocacy for mental health and medical care needs. EX to revoke the Health Caré-Proxy of Respondent. "WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT: Appoint [59 Petitioner oO “FirstName aT ED Some suitable person. TastName ag Biimited guardian(s) [[] general guardian(s) of Respondent, with any specific’authorization as may ba requested in paragraph 15 above. view -rHOmAs Ph leo{Petitioner requests the Court waive sureties on the Bond for the:fallowing reasons: [The Respondent has minimal. fun Respondent. [JA Conservator is appointed of is being requested. Other: This Is a petition for temporary guardianship and does not require surety bond. ds.to be thanaged and requiring suitéties would place a financial burden on the In.addition, Pétitioner requests. that the Court: allow Petitionerto.determine, with guidance:from méntal health and medical professionals providing care to Respondent, ifshe should remain in MA for care or move home with Petitioner/Guardian for continuous care. SIGNED UNDER THE PENALTIES OF PERJURY \ affirm or swear under oath that havé tead the foregoing Petition and that the-statements set forth therein: are true: and correct the best of my knowledge. } Date: _.__ dune 11, 2021 Date: Signature of Co-petitioner (if applicable) { assent.to the foregoing Petition: Print\Name . Signature Attomey for Petitioner Signature of Attorney Print narey TeyiTowny - Ea 257 — PrimaryPhome; B.B.0. # E-mail: