SUPERIOR COURT OF THE DISTRICT OF COLUMBIA Probate Division II-F In re: INTVP: An Adult REPORT OF EXAMINER EXAMINER=S INFORMATION Name: Address: Phone: Fax: Cell: Discipline: Physician (please list specialty) Nurse Practitioner Social Worker Psychologist Other: List any certification, experience, area of specialization or other qualifications relevant to your examination of the subject and preparation of this report. EXAMINATION INFORMATION [Attach additional information, as needed.] Date(s) of Subject=s Examination: Place(s) of Examination: Length of time spent with Subject: 1 American LegalNet, Inc. www.USCourtForms.com List diagnostic tools used, if any, (e.g. Mini Mental Status) See attached medical records Please list other people interviewed in connection with this examination. Include names, relationship to the subject and any available contact information. BACKGROUND INFORMATION (Subject=s demographic history, available medical history, present situation) Gender Age: D.O.B. See attached medical records [Please use a format appropriate to your professional specialty area. Attach additional pages or documents as needed.] ASSESSMENT OF CAPACITY OR INCAPACITY 1. The subject does not have a mental or physical impairment which affects his or her ability to receive and evaluate information effectively or to communicate decisions regarding assets, property and finances, or to meet his or her essential physical health, safety, habilitation or therapeutic needs. Indicate any facts which might support a contrary assessment: 2 American LegalNet, Inc. www.USCourtForms.com OR 2. The subject has a mental or physical impairment, but presently has the capacity to receive and evaluate information effectively or to communicate decisions regarding assets, property and finances, or to meet his or her essential physical health, safety, habilitation or therapeutic needs. Describe the specific nature of the impairment and the basis for this assessment. Indicate any facts which might support a contrary assessment: OR 3. The subject has a mental or physical impairment and because of the impairment(s) the subject of this proceeding is an adult whose ability to receive and evaluate information effectively or to communicate decisions is impaired to such an extent that: a. the subject lacks the capacity to take actions necessary to obtain, administer and dispose of [Check all that apply] real and personal property, intangible property, business property, benefits and income. Describe the specific nature of the incapacity and the basis for this assessment. Indicate any facts which might support a contrary assessment: b. the subject lacks the capacity to take actions necessary [Check all that apply] to make health care decisions, to provide health care, to provide food, clothing and shelter, to provide personal hygiene and other care without which serious physical injury or illness is more likely than not to occur. 3 American LegalNet, Inc. www.USCourtForms.com Describe the specific nature of the incapacity and the basis for this assessment. Indicate any facts which might support a contrary assessment: c. the subject lacks the capacity to meet all or some essential requirements for his or her habilitation or therapeutic needs Describe the specific nature of the incapacity and the basis for this assessment. Indicate any facts which might support a contrary assessment:: If the subject is incapacitated, assess his or her potential for regaining some or all capacity: If the subject is incapacitated, identify any factors which would argue against this Court=s intervention on the subject=s behalf, (e.g. community or family support systems). Other Comments or Recommendations Signature of Examiner Date License # and State Court-appointed Examiners must serve a copy of this report by first class mail upon all persons listed on the Order appointing the Examiner. 4 American LegalNet, Inc. www.USCourtForms.com CERTIFICATE OF SERVICE I hereby certify that on the day of sent by first class mail, as required by SCR-PD 326 and, , 20 this report was faxed served in hand. upon the following persons entitled to receive service in this case. See attached Service List or list persons served here: Signature of Examiner 5 American LegalNet, Inc. www.USCourtForms.com SUPERIOR COURT OF THE DISTRICT OF COLUMBIA Probate Division In re: INTVP: An Adult SERVICE LIST [List names and addresses, of persons entitled to service. See SCR-PD 326. Phone and fax numbers may be included, if known.] 6 (Form PD-1888B/Aug.05.) American LegalNet, Inc. www.USCourtForms.com