PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE GUARDIANSHIP OF CASE NO. STATEMENT OF EXPERT EVALUATION [ This form may only be used for purpose of the Guardian's Report ] Definition of incompetent [ O.R.C. 2111. 01 (D) ]- "An 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 ward incompetent, but is evidence to be considered by the Court. The fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Guardian. 1. This statement of expert evaluation is for the Guardian's Report. [Evaluation and statement by a Licensed Physician, Psychologist, Clinical Social Worker, or Mental Retardation Team to be completed within three months of the date of this report. O.R.C. 2111.49(A)(1)]. Statement completed by: Name: Address: Phone Number: who is a: Licensed Physician Licensed Independent Social Worker Licensed Professional Clinical Counselor 3. Date(s) of evaluation: Place(s) of evaluation: Time spent with ward: Length of time ward has been your patient: Page 1 of 4 FORM 17.15 - STATEMENT OF EXPERT EVALUATION (IN SUPPORT OF GUARDIAN'S REPORT) American LegalNet, Inc. www.FormsWorkFlow.com 2. Licensed Psychologist Mental Retardation Team 10/01/15 CASE NO. 4. Is the ward presently under medication? Yes and purpose. No If yes, what is the medication, dosage, Are there any signs of physical and/or mental impairments caused by the medications themselves? 5. During the examination did you note a disturbance of the ward's: Yes a) Orientation?........................................................................................................ b) Speech?................................................................................................................ c) Motor Behavior?............................................................................................... d) Thought Process?................................................................................................. e) Affect?.................................................................................................................. f) Memory?................................................................................................... g) Concentration and Comprehension?................................................................. h) Judgment?.................................................................................................. I) Perception of Time and Place?..................................................................... No 6. Please describe any abnormalities identified in question five. (Attach addenda if space is not adequate.) 7. Is the ward mentally impaired? Yes No If yes, what is the cause? 8. Is the ward physically impaired? Yes No If yes, what is the cause? Page 2 of 4 FORM 17.15 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 9. Did you consult any collateral information in conjunction with your evaluation? Yes If yes, explain: No 10. Please give a summary of background / historical information obtained from the ward and/or collateral source. 11. Could you determine the general level of intelligence and fund of knowledge of the ward? Yes No If yes, explain: 12. Do you believe this ward in his/her present condition, is substantially capable of managing his/her finances and property? Yes No If yes, explain: 13. Do you believe this ward in his/her present condition, is substantially capable of caring for his/her activities of daily living or making decisions concerning medical treatments, living arrangements, and diet? Yes No If yes, explain: 14. Prognosis: In my opinion a guardianship should be: Continued Terminated Page 3 of 4 FORM 17.15 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Additional Comments I certify that I have evaluated guardianship. for the purpose of Date of Evaluation Evaluator Page 4 of 4 FORM 17.15 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com