PROBATE COURT OF LAKE COUNTY, OHIO MARK J. BARTOLOTTA, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF ____________________________________ Case No. ___________________________ Docket ___________________ Page ____________ STATEMENT OF EXPERT EVALUATION [Sup. R. 66 & R.C. 2111.49] Definition of Incompetent (R.C. 2111.01(D)): " `Incompetent' means any person who is so mentally impaired as a result of a physical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide for his family or other persons for whom he is charged by law to provide, or any person confined to a penal 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 Evaluation is to be filed with or attached to:: A. Guardianship Application: Completed by Licensed Physician or Licensed Official Psychologist prior to filing and attached to the application. B. Guardian's Report: Completed by Licensed Physician or Licensed Official Psychologist Licensed Independent Social Worker Licensed Professional Clinical Counselor or Mental Retardation Team. The evaluation or examination shall be completed within three months prior to the date of the Report. R.C. 2111.49 C. Application for Emergency Guardian: of the person: a Licensed Physician shall complete the Supplement for Emergency Guardian, form 17.1A 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. 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 the individual has been your patient: ______________________________ FORM 17.1 STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.____________________ 4. Is the individual presently under medication? Yes No If yes, what is the medication, dosage, and purpose?________________________________________________ ___________________________________________________________________________ Are there any signs of physical and/or mental impairments caused by the medications themselves?_________________________________________________________________ ___________________________________________________________________________ 5. Is the individual mentally impaired? Yes No If yes, please 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.) Orientation b.) Speech c.) Motor Behavior d.) Thought Process e.) Affect f.) Memory g.) Concentration and comprehension h.) Judgment Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.______________________ 7. Please describe any impairments identified in question six. (Continue comments on page 4). ___________________________________________________________________________ 8. Is the individual psychologically 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 they any indication of abuse, neglect or exploitation of the individual? Yes No If Yes: Explain______________________________________________________________ __________________________________________________________________________ 11. 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? 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? Yes No B. Is the condition reversible? Yes No 14. In my opinion a guardianship should be: Established/Continued 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 medical or psychological certainity, that the mental capacity of this ward will not improve. Date:_________________________ __________________________________________ Signature-Licensed Physician/Clinical Psychologist American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.______________________ ADDITIONAL COMMENTS __________________________________________