LAKE COUNTY PROBATE COURT MARK J. BARTOLOTTA, JUDGE GUARDIAN/VOLUNTEER VISITOR REPORT (Revised 6/2006) IN THE MATTER OF THE GUARDIANSHIP OF ______________________________ CASE NO. ________________________ DOCKET ________________ PAGE _______ Residence or Facility _____________________________ Address (please in_____________________________ Included name of facility) _____________________________ Check if new address What is the visitor's view of the ward's overall situation, including any significant changes in physical health, intellectual functioning, emotional health and living situation that have occurred since the last visit? ______________________________________________________________________________________ ______________________________________________________________________________________ Visitor's rating of the ward's "quality of life" situation at the time of this visit (complete all response areas using the following rating scale: 1 = Poor, 2 = Fair, 3 = Good, 4 =Excellent): Safety and Cleanliness of Environment ________ Physical Needs are being met ________ Activities of Daily Living are being met _________ Medical Needs are being met _________ Are there any circumstances that indicate that changes are needed in the guardianship? Yes No. If yes, explain: ___________________________________________________________ Are any changes requested by the ward or others? Yes No. If yes, explain: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Does the ward need assistance, whether from the court or from a community agency? Yes No. If yes, explain: ____________________________________________________________ Is the ward able to make decisions? Yes No. If yes, in what areas? ______________________________________________________________________________________ Visitor recommends the following action by the court: (1) No further action needed _________________________________ (2) Ward should be visited again in ____________________________ (3) Case requires further investigation _________________________ Name of Visitor (Print and Sign) Address and Phone No. Date of Visit Check one: Guardian Visitor ________________________________ ________________________________ ________________________________ Hours spent________ Please return to: Lake County Probate, 25 N. Park Place, Painesville, OH 44077 1 You may omit answers to questions you do not feel capable of answering. American LegalNet, Inc. www.FormsWorkFlow.com