FOR CLERK'S USE ONLY Name of Person Filing: ___________________________________________ Mailing Address: ___________________________________________ City, State, Zip Code: ___________________________________________ Day/Evening Telephone: ___________________________________________ Attorney Bar Number (if applicable) ______________________________________ Representing: Self (Without a Lawyer) or Attorney for _________________________________ SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of Guardianship and/or Conservatorship of Case Number GC: _____________________ REPORT OF COURT-APPOINTED PHYSICIAN / PSYCHOLOGIST / REGISTERED NURSE An Adult Pursuant to Arizona Revised Statutes §14-5303(D), ________________________________ submits the following report concerning ________________________ (the "patient") based on the examination of said person done on ___________________, 20______. 1. The specific physical, psychiatric, or psychological diagnosis of the patient is as follows: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. A comprehensive assessment listing any functional impairments of the patient and an explanation of how and to what extent these functional impairments may prevent that person from receiving or evaluating information in making decisions or in communicating informed decisions regarding that person is as follows: __________________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________________ Revised: 6/23/2011 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No.___________________________ 3. The patient is capable of performing the following tasks of daily living without direction or with minimal direction: __________________________________________________________________________________ __________________________________________________________________________________ 4. The patient is receiving the following medications in the following dosages and, to the best of my knowledge those medications have the following effects on the patient's behavior: __________________________________________________________________________________ __________________________________________________________________________________ 5. The prognosis for improvement in the patient's condition and my recommendation for the most appropriate rehabilitation plan or care plan are as follows: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. The least restrictive living arrangement reasonable available for the patient would be: __________________________________________________________________________________ __________________________________________________________________________________ 7. The patient cannot or should not appear in court for the following reasons: __________________________________________________________________________________ __________________________________________________________________________________ 8. The patient requires a guardian to be appointed by the Court because: __________________________________________________________________________________ __________________________________________________________________________________ Revised: 6/23/2011 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________ 9. The patient should/should not be allowed to drive (circle one). 10. Mr./Ms._____________________________ has been my patient for ________days / weeks / months / years (circle one). 11. 12. I am a physician/psychologist/registered nurse (circle one). In addition to the foregoing, the Court should know the following about the patient: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ________________________ __________________________________________________ Date Signature __________________________________________________ Printed Name: __________________________________________________ Address __________________________________________________ Telephone Revised: 6/23/2011 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com