FORM MUST BE TYPEWRITTEN OR CAN BE FILLED IN ON-LINE USING THE FORM AT THE COURT’S WEBSITE PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF GUARDIANSHIP OF CASE NO. STATEMENT OF EXPERT EVALUATION [Sup. R. 66 & R.C. 2111.49] Definition of Incom petent [O.R.C. 2111.01(D)]: “”Incom petent” m eans any person who is so m entally im paired as a result of a m ental or physical illness or disability, or m ental retardation, or as a result of chronic substance abuse, that the person is incapable of taking proper care of the person’s self or property or fails to provide for the person’s fam ily or other persons for whom the person is charged by law to provide, or any person confined to a penal institution within this State.” The Statem ent of Evaluation does not declare the individual com petent or incom petent, but is evidence to be considered by the Court. The fee for com pleting this evaluation WILL NOT be paid by the Court. Each evaluator should secure paym ent from the Applicant/Guardian. 1. This Statem ent of Evaluation is to be filed with or attached to: 9 A. 9 Licensed Physician or Guardianship Application: Com pleted by 9 Licensed Clinical Psychologist prior to the filing and attached to the application. 9 B. Guardian's Report: Com pleted by 9 9 Licensed Physician 9 Licensed Independent Social Worker 9 Licensed Clinical Psychologist Licensed Professional Clinical Counselor or 9 M ental Retardation Team . The evaluation or exam ination shall be com pleted within three m onths prior to the date of the Report. R.C. 2111.49 9 C. Application for Em ergency Guardian: 9 of the person: a Licensed Physician shall com plete the Supplem ent for Em ergency Guardian, form 17.1A with specificity indicating the em ergency, and why im m ediate action is required to prevent significant injury to the person. The Supplem ent shall be signed, dated, and attached as part of this com pleted Statem ent. 2. Statem ent com pleted by: Nam e & Title/Profession: Business Address: Business Telephone Num ber: 3. Date(s) of evaluation: Place(s) of evaluation: Am ount of tim e spent on evaluation: Length of tim e the individual has been your patient: FORM 17.1 - STATEMENT OF EXPERT EVALUATION -PDF - Page 1 06/2006 American LegalNet, Inc. www.FormsWorkflow.com Case No. 4. Is the individual presently under m edication? 9 Yes 9 No If yes, what is the m edication, dosage, and purpose? Are there any signs of physical and/or m ental im pairm ents caused by the m edications them selves? 5. 9 Yes Is the individual m entally im paired? 9 9 No If yes, indicate the diagnosis below: M ental Retardation/Developm ental Disabilities: 9 9 Profound 9 M ental Illness: 9 Substance Abuse: 9 Dem entia: 9 Other: 9 Severe 9 M oderate M ild Type and Severity Description Description Description Please provide additional com m ents and test scores if available. (Continue com m ents on page 4): 6. During the exam ination did you note an im pairm ent of the individual’s: a) 9 Yes 9 No 9 Unknown b) Speech? 9 Yes 9 No 9 Unknown c) M otor Behavior? 9 Yes 9 No 9 Unknown d) Thought Process? 9 Yes 9 No 9 Unknown e) Affect? 9 Yes 9 No 9 Unknown f) M em ory? 9 Yes 9 No 9 Unknown g) Concentration and com prehension? 9 Yes 9 No 9 Unknown h) 7. Orientation? Judgm ent? 9 Yes 9 No 9 Unknown Please describe any im pairm ents identified in question six. (Continue com m ents on page 4) FORM 17.1 - STATEMENT OF EXPERT EVALUATION -PDF - Page 2 06/2006 American LegalNet, Inc. www.FormsWorkflow.com Case No. 9 9 8. Is the individual physically im paired? 9. Are there any special characteristics of the individual which should be considered in evaluating the 9 individual for guardianship: Yes 9 Yes No No If yes: If yes: Description Explain 10. Are there any indications of abuse, neglect or exploitation of the individual? 9 Yes 9 No If yes: Explain 11. Do you believe the individual is capable of caring for the individual’s activities of daily living or m aking decisions concerning m edical treatm ents, living arrangem ents and diet? 9 Yes 9 No If no: Explain: 12. Do you believe this individual is capable of m anaging the individual’s finances and property? 9 9 Yes No If no: Explain: 13. Prognosis: A. Is the condition stabilized? 9 Yes 9 No B. Is the condition reversible? 9 Yes 9 No 14. In m y opinion a guardianship should be: 9 Established/Continued 9 Denied/Term inated I certify that I have evaluated the individual on Date , . Signature of Evaluator GUARDIAN’S REPORT ADDENDUM (Not to be used with initial Application) It is my opinion, based upon a reasonable degree of medical or psychological certainty, that the mental capacity of this ward will not improve. Date Signature - Licensed Physician/Clinical Psychologist FORM 17.1 - STATEMENT OF EXPERT EVALUATION -PDF - Page 3 06/2006 American LegalNet, Inc. www.FormsWorkflow.com Case No. ADDITIONAL COMMENTS Date Signature - Licensed Physician/Clinical Psychologist FORM 17.1 - STATEMENT OF EXPERT EVALUATION -PDF - Page 4 06/2006 American LegalNet, Inc. www.FormsWorkflow.com