IN THE CIRCUIT COURT FOR FLORIDA IN RE: COUNTY, PROBATE DIVISION File No. Division an alleged incapacitated person REPORT OF EXAMINING COMMITTEE MEMBER The undersigned, being a member of the committee appointed to examine , reports that such examination, as directed by the Order Appointing Examining Committee, has been completed. comprehensive examination, with evaluations and recommendations, is as follows: I. GENERAL INFORMATION The report of the Name of person being examined Date of birth Residence of person Date and time of examination Names of all persons present during the examination If a person other than the subject of the examination answers questions posed to the alleged incapacitated person, specify the name of the person and the information provided. _______________________________ Name and address of extended care facility (if any) Alleged incapacity is DIAGNOSIS (short summary) Bar Form No. G-2.051 - 1 of 4 � Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com PROGNOSIS (short summary) RECOMMENDED COURSE OF TREATMENT (short summary) II. EVALUATION OF ALLEGED INCAPACITATED PERSON'S ABILITY TO RETAIN HIS OR HER RIGHTS (WITHOUT LIMITATION) THE EXAMINING COMMITTEE IS CHARGED WITH DETERMINING WHETHER THE ALLEGED INCAPACITATED PERSON HAS THE ABILITY TO EXERCISE THOSE RIGHTS SPECIFIED IN FLORIDA STATUTES SECTION 744.3215(2) & (3) WHICH THE PETITIONER HAS REQUESTED BE REMOVED IN THE PETITION TO DETERMINE INCAPACITY. The alleged incapacitated person has the capacity to: (Circle yes or no) YES YES YES NO NO NO Make and exercise informed decisions regarding his/her right to marry. Make and exercise informed decisions regarding his/her right to vote. Make and exercise informed decisions regarding his/her right to personally apply for government benefits. Make and exercise informed decisions regarding his/her right to have a driver's license and operate a motor vehicle. Make and exercise informed decisions regarding his/her right to travel. Make and exercise informed decisions regarding his/her right to seek or retain employment. Make and exercise informed decisions regarding his/her right to contract. Make and exercise informed decisions regarding his/her right to sue, or assist in the defense of suits of any nature against him or her. Make informed decisions regarding and exercise his/her right to manage property or to make any gift or disposition of property. Make and exercise informed decisions determining his/ her residence. Make and exercise informed decisions regarding his/her right to consent to medical and mental health treatment. Make informed decisions affecting the social environment or other social aspects of his/her life. YES YES YES YES YES NO NO NO NO NO YES YES YES NO NO NO YES NO Bar Form No. G-2.051 - 2 of 4 � Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com III. PHYSICIAN'S REPORT Please give the results of the comprehensive examination and the committee member's assessment of information provided by the attending or family physician, if any. Attach extra sheets if necessary. If the attending or family physician is available for consultation, the committee must consult with the physician. Physical Examination: Mental Health Examination: Functional Assessment: If any of the three parts of the comprehensive examination were not indicated or could not be accomplished for any reason, the reason for the omission must be explained. Consultation with Family Physician: Yes _____ No _____. If no, why? Assessment of information provided by attending or family physician, if any: Bar Form No. G-2.051 - 3 of 4 � Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com Assessment of prior clinical history, treatment records, social records, and reports, if any: Please list specific evidence of the person's incapacity to exercise informed decisions in the categories previously checked: IV. SCOPE OF GUARDIANSHIP (IF ANY) If the examiner has determined that the alleged incapacitated person is incapacitated and if the court finds guardianship to be necessary, the scope of the guardianship recommended is: PLENARY LIMITED I certify that I have examined the alleged incapacitated person in accordance with the requirements of Florida Statutes Section 744.331, performing the examination necessary to determine which, if any, of the rights the petitioner has requested to be removed the allegedly incapacitated person can no longer sufficiently nor adequately exercise. These conclusions, evaluations and recommendations are hereby presented to the Court. I do have knowledge of the type of incapacity alleged in the Petition to Determine Incapacity. Executed this day of , . Signature Typed or printed name A copy of this report has been served on the petitioner's attorney and the court appointed attorney for the alleged incapacitated person by on , ___________. [Print or Type Names Under All Signature Lines] Bar Form No. G-2.051 - 4 of 4 � Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com