IN THE CIRCUIT COURT OF THE TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS Probate Division IN THE MATTER OF ) ) ) ) ) ) ) Case Number_______________________________ ______________________________________________ An Alleged Disabled Person EVALUATION REPORT 1. The undersigned, being a physician licensed to practice medicine in all its branches in the State of Illinois, examined___________________________________________________, hereinafter called the Respondent, on _____________________________________________, 20________. 2. The following is an assessment, based on my examination, of the Respondent's disability and how such disability impacts on the ability of the Respondent to make decisions or to function independently: __________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 3. The following is my evaluation of the Respondent's physical and educational condition, adaptive behavior and social skills: a) Mental condition:________________________________________________________________________ ______________________________________________________________________________________ b) Physical condition:_______________________________________________________________________ ______________________________________________________________________________________ c) Educational condition:____________________________________________________________________ ______________________________________________________________________________________ d) Adaptive behavior:_______________________________________________________________________ ______________________________________________________________________________________ e) Social Skills:___________________________________________________________________________ ______________________________________________________________________________________ PR-REP2: Revised 12/01/06 Page 1 of 2 Disabled Guardianship American LegalNet, Inc. www.FormsWorkflow.com 4. Based on my examination and evaluation of the Respondent, it is my opinion that: Guardianship is not needed. Guardianship is needed, and the type and scope of the guardianship needed and the reasons therefore are as follows:___________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 5. My recommendations as to the most appropriate treatment or habitational plan and living arrangement for the Respondent and the reasons therefore are as follows:_______________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 6. The signatures of all persons who performed the evaluation upon which this report is based, one of whom shall be a licensed physician, as well as a statement of the certification, license or other credentials which qualify any evaluators. The evaluations were performed within three (3) months of the filing of the petition: PREPARER OF REPORT: ____________________________________________________________________________________________ Name Profession/Credentials Date of evaluation PERFORMERS OF EVALUATION UPON WHICH THIS REPORT IS BASED: ____________________________________________________________________________________________ Name Profession/Credentials Date of evaluation ____________________________________________________________________________________________ Name Profession/Credentials Date of evaluation ____________________________________________________________________________________________ Name Profession/Credentials Date of evaluation PR-REP2: Revised 12/01/06 Page 2 of 2 Disabled Guardianship American LegalNet, Inc. www.FormsWorkflow.com