PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE GUARDIANSHIP OF___________________________________________________________ CASE NO.__________________________ COURT INVESTIGATOR'S REPORT ON PROPOSED GUARDIANSHIP [R.C. 2111.041] GENERAL INFORMATION [To be compiled by Probate Court Investigator] Individual's age ________________ Relationship to applicant _______________________ Individual's residence __________________________________________________________ Grounds for application (R.C. 2111.01 (D)): mentally impaired as a result of a mental illness or disability. mentally impaired as a result of a physical illness or disability. mentally impaired as a result of mental retardation. mentally impaired as a result of chronic substance abuse. any person confined to a correctional institution within this state. so that the individual is incapable of taking proper care of the individual's self. the individual is incapable of taking proper care of the individual's property. the individual fails to provide for the individual's family or other individual for whom the person is charged by law to provide. Documentation submitted and date of evaluation _____________________________________ Referral Source: ______________________________________________________________ PAGE 1 OF 7 S.P. FORM 17.8 ­ COURT INVESTIGATOR'S REPORT ON PROPOSED GUARDIANSHIP 10/01/07 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ____________________ INVESTIGATOR'S REPORT I. Service of Notice Made at Individual's home Made in Hospital, Nursing Facility, or Community-Based Care Facility: Name of Facility _______________________________________________________________ Address of Facility ______________________________________________________________ Administrator or representative served ________________________________________________ Other _____________________________________________________________________ Date of Service of Notice: ________________________________________________________ Other present during the contact (if yes, list name and relationship) ___________________________ ____________________________________________________________________________ A. Individual's understanding of the concept of guardianship: Good Fair Poor Unable to determine. Explain: ____________________________________________________________________ __________________________________________________________________________. B. Individual's attitude to the concept of guardianship: Consenting Opposed Unable to Determine. Explain: ____________________________________________________________________ __________________________________________________________________________. C. Specific requests of the individual concerning enumerated rights: ____________________ __________________________________________________________________________. II. Mental and Physical Conditions of Individual A. Individual's reported mental and physical diagnosis: ______________________________ Individual's reported medications: _______________________________________________ Reported by whom: __________________________________________________________ PAGE 2 OF 7 S.P. FORM 17.8 ­ COURT INVESTIGATOR'S REPORT OF PROPOSED GUARDIANSHIP 10/01/07 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ____________________ B. Mental Status Observations: During interview were impairments noted in the Individual's Yes 1. Orientation (Person, Place and Time) 2 Speech 3. Thought Process 4. Affect 5. Memory 6. Concentration & Comprehension 7. Judgment Explain further if necessary: _______________________________________________________ No Unable to Determine ____________________________________________________________________________ C. Describe the Physical Condition of Individual 1. Isolation ___________________________________________________________________ 2. Eating Habits _______________________________________________________________ 3. Significant Weight Loss or Gain __________________________________________________ 4. Sleep Habits _______________________________________________________________ 5. Motor Behavior _____________________________________________________________ Explain further if necessary: _______________________________________________________ ____________________________________________________________________________ D. Describe the Environmental or Living Condition of the Individual: 1. Housing & Sanitation _________________________________________________________ 2. Risk of Accidents ____________________________________________________________ 3. Physical Barriers ____________________________________________________________ 4. Resource Availability _________________________________________________________ Explain further if necessary: _______________________________________________________ ____________________________________________________________________________ III. Functional Capacities Activities and Instrumental Activities of Daily Living Capable 1. 2. 3. 4. 5. Eating Dressing Transfer from bed Toileting Bathing S.P. FORM 17.8 ­ COURT INVESTIGATOR'S REPORT ON PROPOSED GUARDIANSHIP 10/01/07 Incapable Unable to Determine PAGE 3 OF 7 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ____________________ Capable 6. Handling personal finances 7. Shopping 8. Driving 9. Meal Preparation 10. Doing housework 11. Using telephone 12. Taking medications Explain further if necessary: Incapable Unable to Determine ____________________________________________________________________________ ____________________________________________________________________________ IV. Additional Items Affecting Guardianship Plan Development A. Are there any indications or allegations of substance abuse by the individual or significant other that could impact the guardianship issue? Yes No Explain and recommend actions needed: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ B. Are there any special characteristics of the individual (including aggressive, violent, or sexual behaviors, or other vulnerabilities) that pose a risk to self or others, which should be considered as guardianship decisions on living arrangements and supervision are made? Yes No Explain the characteristics and recommend actions needed: ____________________________ ________________________