GUIDELINES FOR FOR CLERK'S USE ONLY HEALTH PROFESSIONAL'S REPORT INSTRUCTIONS TO PETITIONER: Fill in the information below and give this document to the physician, registered nurse, or psychologist appointed by the Court to evaluate the health of the person said to need protection immediately after the "ORDER APPOINTING (Attorney, Health Professional, and Court Investigator)" is signed. The complete written report should be given to everyone listed in the "ORDER APPOINTING" no later than 10 days before the scheduled hearing. COURT CASE NUMBER: NAME OF EVALUATOR: PB EVALUATOR'S PROFESSION: NAME OF PATIENT (subject of this evaluation): Physician Registered Nurse Psychologist (Person said to need guardian) NAME OF PETITIONER: PETITIONER'S TELEPHONE NUMBER: DATE AND TIME OF COURT HEARING: INSTRUCTIONS TO PHYSICIAN OR OTHER EVALUATOR: A court case has been filed that asks the court to appoint a guardian for the person named as "Patient" above. Before granting such a petition, the court must decide if mental, physical, or other cause exists which requires appointment of a guardian. To make that decision, the Court needs to know what you think about: � the person's mental and physical health, and � whether the person needs inpatient mental health treatment, and � whether the person's driving privileges should be suspended. The court has developed this form to make it easier for you to prepare your report. You may submit your report using this form or in any format you choose, but please provide the same type of information as provided for on this form. Note that if the Petitioner is seeking authority to consent to inpatient mental health treatment this report or a separate report recommending such authority must be signed by a licensed psychologist or psychiatrist. (A.R.S. � 14-5303(C)) After you complete the report, give the original report to the Petitioner, who is responsible for distributing copies to the proper parties. Please do not file your report with the Clerk of the Court. PLEASE DATE AND SIGN YOUR REPORT. The Court realizes that your time is valuable. THANK YOU FOR YOUR TIME AND ASSISTANCE. � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBGCA15f-080816 Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No. _____________________ QUESTIONS FOR HEALTH PROFESSIONAL TO ANSWER: Note: If not enough space on this form to answer, write in "See attached" and respond on separate page. Please re-state the question on the attachment and use same number as from this document. 1. 2. What is the date you last saw the patient? How long have you been treating the patient? 3. Why were you asked to do this evaluation? I have been the person's physician for many years. I was asked to do so by the family. I was selected by an attorney. My office is close to the person's residence. I am a doctor, registered nurse, or psychologist, for the person's nursing home. Other: 4. What is your area of specialty? Are you Board Certified in this area? In any other areas? If "yes", list: Yes Yes No No 5. Does the person you are evaluating appear to be having difficulty in any of the following areas? Mental disorder Chronic intoxication or drug use Anything else (explain below) Physical illness Cognitive abilities Physical illness ONLY 6. If he or she is having difficulty, please specify the nature of the illness, disorder, etc., including diagnosis: 7. Has the person been treated or hospitalized before for this difficulty? If yes, when and where? Yes No � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBGCA15f-080816 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No. _____________________ 8. Is the person able to do the following things? Please check each applicable box. Pay his or her bills Take medication appropriately Obtain food Provide adequate housing Live alone Exercise daily self-help skills Make appropriate judgments that will protect him or her personally, physically, or financially Drive a motor vehicle. (If "yes", explain below.) If you believe a guardianship is warranted but you believe the person to be protected is capable of and should be permitted to drive a motor vehicle, please explain. 9. If the person is currently on medication, please list: 10. Do you believe that the medication is affecting the person's ability to respond coherently? Yes Do you believe that the medication is affecting the person's ability to ambulate? Yes No No 11. 12. Do you believe that a "medication holiday," if possible, would help you better evaluate the person? Yes No Do you believe that any changes made in the type or amount of drugs the person is receiving would noticeably affect his or her mental or physical abilities? Yes No Do you believe that any further medical evaluation or treatment would benefit the person? Yes If so, please give your recommendation: 13. 14. No 15. Do you think the person would benefit from other types of therapy such as counseling? Yes No If yes, describe: � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBGCA15f-080816 Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No. _____________________ 16. Where do you think the person should live today? At home with a companion At home with a nurse In a group home In a boarding home In a supervisory care facility In a nursing home In a hospital In an Inpatient Psychiatric Facility for inpatient mental health treatment. Explain. Other -- please explain. 17. Do you believe that the person's condition could improve within 6 months to a year? Yes No 18. Is there is any reason for the court to review this matter again within less than one year? Yes No 19. Please make any additional comments or suggestions you think would be helpful to the court in making this decision. MENTAL HEALTH TREATMENT ISSUES (This section must be completed IF the petitioner is requesting authority for a guardian to consent to inpatient mental health treatment, and if so, this report or a separate report covering this information must be completed and signed by a licensed psychologist or psychiatrist.) Note: If not enough space on this form to answer, write in "See attached" and respond on separate page. Please re-state the question on the attachment and use same number as from this document. 1. Is it the opinion of the undersigned that the patient is incapacitated as a result of a mental disorder? Yes No What is the mental disorder? 2. � Superior Court of Arizona in Maricopa