In The Circuit Court001 For The Seventh Judicial Circuit of Illinois001 Sangamon County, Springfield, Illinois001 IN THE MATTER OF THE GUARDIANSHIP OF Case No. An Alleged Disabled Person REPORT OF PHYSICIAN AND OTHER EVALUATORS The undersigned, a physician licensed to practice medicine in all its branches, in the State of Illinois, haslhave performed physical, psychological, and/or psychiatric exterminations or tests on the above named person on and finds that he/she is a disabled adult as defined in 755 ILCS 5/11 a-I, et seq. In support thereof it is set forth: 1. Description of the nature and type of individual's disability: 2. The above described disability impacts on the individual's ability to make decisions or to function independently in the following ways: 3. An analysis and results of evaluations performed on the individual's mental, physical and educational condition, adaptive behavior and social skills: 4. In my/our opinion: a. Guardian is/is not needed001 b.lfneeded-001I. Plenary 2. Limited to the following: c. For the following reasons: American LegalNet, Inc. www.FormsWorkFlow.com 5. A recommendation as to the most appropriate treatment or habilitation plan living arrangement for the individual and the reasons therefore: Signatures of all persons who performed the evaluations upon which the report is based and a description of their certification, license of other credentials that qualify the evaluators who prepared the report. One of the signers must be a licensed physician. Physician Evaluator Evaluator License, Certification of Credentials: NOTES: 755 ILCS 5/1 la-I et seq. 5/11 a-I. "Developmental disability" means a disability which is attributable to :(a) mental retardation, cerebral palsy, epilepsy or autism: or to (b) any other condition which results in impairment similar to that caused by mental retardation and which requires services similar to those required by mentally retarded persons. Such disability must originate before the age of 18 years, be expected to continue indefinitely, and constitute a substantial handicap. 5/1 1a-2. "Disabled person" means a person of 18 years or older who (a) because of mental deterioration or physical incapacity is not FULLY able to manage his person or estate, or (b) is mentally ill or developmentally disabled and who because of his mental illness or developmental disability is not fully able to manage his person or estate, or (c) because of gambling, idleness, debauchery or excessive use of intoxicants or drugs, so spends or wastes his estate as to expose himself or his family to want or suffering. 5/11a-9. (a) The petition for appointment ofa guardian should be accompanied by a report which contains (l) a description of the nature and type of the respondent's disability; (2) evaluations of the respondent's mental, physical and educational condition, adaptive behavior and social skills; (3) an opinion as to whether guardianship is needed, the type and scope of the guardianship needed, and the reasons therefore: (4) a recommendation as to the most appropriate treatment or habilitation plan and living arrangement for the respondent and the reasons therefore: (5) the signatures of ALL PERSONS who performed the evaluations upon which the report is based, one of whom shall be a licensed physician. American LegalNet, Inc. www.FormsWorkFlow.com