PC-G-17.1A (Rev. 9-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. STATEMENT OF EXPERT EVALUATION [Sup. R. 66 & R.C. 2111.49] Definition of incompetent [O.R.C.2111.01 (D)]: "Incompetent" means any person who is so mentally impaired as a result of a mental or physical 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 the person 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 this evaluation WILL NOT be paid by the Probate Court. Each evaluator should secure payment from the Applicant/Guardian. 1. This Statement of Expert Evaluation is to be filed with or attached to: A. Guardianship Application: Completed by Licensed Physician prior to the filing and attached to the application. Licensed Clinical Psychologist B. Guardian's Report: To be completed by Licensed Physician Licensed Clinical Psychologist Licensed Independent Social Worker Licensed Professional Clinical Counselor or Mental Retardation Team The evaluation or examination shall be completed within three months prior of the date of the Report. O.R.C.2111.49. C. Application for Emergency Guardian: of the person; a Licensed Physician shall complete the Supplement For Emergency Guardian, Form 17.1B, 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 Statement. 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 on evaluation: Length of time individual has been your patient: American LegalNet, Inc. www.FormsWorkFlow.com psoe FRANKLIN COUNTY FORM 17.1A - STATEMENT OF EXPERT EVALUATION (PAGE 1) 4. Is the individual presently under medication? purpose? Yes No If yes, what is the medication, dosage, and CASE NO. Are there any signs of physical and/or mental impairments caused by the medications themselves? 5. Is the subject mentally impaired? Yes No If yes, indicate the diagnosis below: Mental Retardation/Developmental Disabilities: Profound Severe Moderate Mild Mental Illness: Type and Severity Substance Abuse: Description Dementia: Description Other: 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) b) c) d) e) f) g) h) Orientation................................................ Speech ..................................................... Motor Behavior ......................................... Thought Process ...................................... Affect........................................................ Memory .................................................... Concentration and comprehension ........... Judgment ................................................. Yes ......... Yes ......... Yes ......... Yes ......... Yes ......... Yes ......... Yes ......... Yes ......... No ........ No ........ No ........ No ........ No ........ No ........ No ........ No ........ Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown 7. Please describe any impairments identified in question six. (Continue comments on page 4) psoe FRANKLIN COUNTY FORM 17.1A - STATEMENT OF EXPERT EVALUATION (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 8. Is the subject physically impaired? Yes No If yes, description: 9. Are there any special characteristics of the individual which should be considered in evaluating the individual for guardianship? Yes No If yes, explain: 10. Are there any indications of abuse, neglect or exploitation of the individual? Yes No If yes, explain: 11. Do you believe this individual is capable of managing the individual's activities of daily living or making decisions concerning medical treatments, living arrangements and diet? Yes No If no, explain: 12. Do you believe this individual is capable of managing the individual's finances and property? Yes No If no, explain: 13. Prognosis: A. Is the condition stabilized? B. Is the condition reversible? Yes Yes No No Established/Continued , 20 License Number Date 14. In my opinion a guardianship should be: Denied/Terminated . I certify that I have evaluated the individual on Signature of Evaluator Printed Name (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 Printed Name License Number psoe FRANKLIN COUNTY FORM 17.1A - STATEMENT OF EXPERT EVALUATION (PAGE 3) American LegalNet, Inc. www.FormsWorkFlow.com GUARDIAN'S REPORT ADDENDUM CASE NO. ADDITIONAL COMMENTS Date: Signature - Licensed Physician/Clinical Psychologist psoe FRANKLIN COUNTY FORM 17.1A - STATEMENT OF EXPERT EVALUATION (PAGE 4) American LegalNet, Inc. www.FormsWorkFlow.com