PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge IN THE MATTER OF THE GUARDIANSHIP OF _______________________________________ CASE NUMBER:______________________________________ STATEMENT OF EXPERT EVALUATION [Sup. R. 66 & R.C. 2111.49] Definition of Incompetent (R.C. 2111.03(D)): "Incompetent" means any person who is so mentally impaired as a result of a physical or mental illness or disability, or mental 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 family or other persons for whom he is charged by law to provide, or any person confined to a correctional institution within this State." The Statement of Evaluation does not declare the individual competent or incompetent, but is evidence to be considered by the Court. The fee for completing the evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant/Guardian.. 1. This Statement of Expert Evaluation is to be filed with the attached to: 9 9 A. Guardianship Application. Completed by 9 Licensed Physician or Clinical Psychologist prior to the filing and attached to the application. Guardian's Report: Completed by 9 Licensed B. 9 Licensed Physician or 9 Licensed Clinical Psychologist 9Licensed Independent social worker 9Licensed professional Clinical Counselor or 9 Mental RetardationTeam Application for emergency Guardian 9 of the person: a Licensed Physician shall complete the Supplement for Emergency Guardian, Form 17.1 A with specificity indicating the emergency, and why immediate action is required to prevent significant injury to the person. The supplement shall be signed, dated, and attached as part of this completed Statement. 9 C. 2. Statement completed by: Name & Title Profession: __________________________________________________________ Business Address: ________________________________________________________________ Business Telephone Number: ______________________________________________________ 3. Date(s) of evaluation: ______________________________________________________________ Place(s) of evaluation: ____________________________________________________________ Amount of time spent of evaluation: __________________________________________________ Length of time the individual has been your patient: _____________________________________ 17.1 Statement of Expert Evaluation American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER:__________________________ 4. 9 No If yes, What is the medication, Is the individual presently under medication? 9 Yes dosage, and purpose? ____________________________________________________________ _______________________________________________________________________________ Are there any signs of physical and/or mental impairments caused by the medication themselves? ________________________________________________________________________________ 5. Is the individual mentally impaired? 9 Yes 9 No If yes, indicate the diagnosis below: 9 mental retardation/Developmental Disabilities: 9 Profound 9 Severe 9 Moderate 9 Mild 9 Mental Illness: Type and Severity __________________________________________________ _______________________________________________________________________________ 9 Substance Abuse: Description ____________________________________________________ _______________________________________________________________________________ 9 Dementia: Description __________________________________________________________ _______________________________________________________________________________ 9Other: Description ______________________________________________________________ _______________________________________________________________________________ Please provide additional comments and test scores if available. (Continue comments on page 4): ___________________________________________________ _______________________________________________________________________________ 6. During the examination did you notice an impairment of the individual's: a) Orientation b) Speech c) Motor Behavior d) Thought process e) Affect f) Memory g) Concentration and comprehension h) Judgement 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 No 9 No 9 No 9 No 9 No 9 No 9 No 9 No 9 9 9 9 9 9 9 9 Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown 7. Please describe any impairments identified in question six. (Continue comments on page 4) _________________________________________________________________________ _________________________________________________________________________ Page 2 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER:_______________________ 8. 9 No If yes: Description Is the individual physically impaired? 9 Yes _________________________________________________________________________________ Are there any special characteristics of the individual which should be considered in evaluating the individual for guardianship?: 9. 9 Yes 9 No If yes: Explain 10. Are there any indications of abuse, neglect or exploitation of the individual? 9 Yes 11. 9 No If yes: Explain ____________________________________________________ _________________________________________________________________________________ 9 No If no: Explain _________________________________________________________________________________ _________________________________________________________________________________ 9 No Do you believe the individual is capable of caring for the individual's activities of daily living or making decisions concerning medical treatments, living arrangements and diet? 9 Yes 12. Do you believe this individual is capable of managing the individual's finances and property? If no: Explain ________________________________________________________________________________ ________________________________________________________________________________ 9 Yes 13. Prognosis: A. B. Is the condition stabilized? Is the condition reversible? 9 Yes 9 Yes 9 No 9 No 14. In my opinion a guardianship should be: 9 Established/Continued 9 Denied/Terminated I certify that I have evaluated the individual on _________________________ , 20_________ . 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