SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ In re ________________________________ An Adult _________ IDD _________ 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 November 2015 � 941.10.v3 American LegalNet, Inc. www.FormsWorkFlow.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 ____________ 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 that might support a contrary assessment: ___________________________________________________________________ ___________________________________________________________________ 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 that might support a contrary assessment: ___________________________________________________________________ ___________________________________________________________________ OR 2 November 2015 � 941.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com 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 that 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. Describe the specific nature of the incapacity and the basis for this assessment. Indicate any facts that 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): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3 November 2015 � 941.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com Other Comments or Recommendations: ______________________________