PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, 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)): The individual is alleged to be: 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 No Unable to Determine 1. Orientation (Person, Place and Time) 2 Speech 3. Thought Process 4. Affect 5. Memory 6. Concentration & Comprehension 7. Judgment Explain further if necessary: _______________________________________________________ ____________________________________________________________________________ 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 Incapable Unable to Determine 1. Eating 2. Dressing 3. Transfer from bed 4. Toileting 5. Bathing PAGE 3 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. ____________________ 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: ____________________________ ____________________________________________________________________________ ___________________________________________________________________________________ C. Are there any allegations or indications of abuse, neglect, or exploitation of the individual? Yes No Explain and recommend needed actions: ___________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ D. Is there a need for additional medical, psychiatric or psychological testing? Yes No If yes, give specific recommendations: _____________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PAGE 4 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. ____________________ E. Are there inconsistencies between the Expert Evaluation and the Court Investigator’s findings that need further review by the Court? Yes No If yes, identify the inconsistencies and make a recommendation(s) to the Court: ________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ F. Are there unresolved issues/conflicts/differences among the parties? Yes No If yes, would medication be of assistance? Yes No Explain: _____________________________________________________________________ ____________________________________________________________________________ G. Is there a power of attorney for financial affairs? Yes No Unknown If yes, where is it located? ____________________________________________________________________________ Who is the attorney-in-fact? _____________________________________________________ H. Is there a last will and testament? Yes No Unknown If yes, where is it located? _______________________________________________________ I. Is there a durable power of attorney for health care/living will? Yes No Unknown If yes, where is it located? _______________________________________________________ Give name and address of attorney-in-fact: _________________________________________ J. Is there an advance directive for mental health care? Yes No Unknown If yes, where is it located? ____________________________________________________________ Give name and address of attorney-in-fact: _________________________________________ K. Is the individual a veteran? Yes No PAGE 5 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. ____________________ V. RECOMMENDATIONS: Given the above information and Expert Evaluation(s): A. IS A GUARDIANSHIP NECESSARY? Yes Person Only Estate Only Person and Estate Limited List Duties _________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ No Explain and recommend a less restrictive alternative: _________________________ ____________________________________________________________________________ ____________________________________________________________________________ Are any of the mental, physical, or environmental conditions reversible? Yes No Unknown If yes, explain and recommend a date for the Court to review the guardianship ______________ ____________________________________________________________________________ B. NECESSITY FOR THE APPOINTMENT OF: Attorney Independent Expert Evaluator Are there special urgency needs? Explain: _________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Remarks: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PAGE 6 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. ____________________ I certify that I have served notice to the alleged incompetent as required by statute and I have communicated to the individual in a language and method best understandable by the individual the individual’s right to be present at the hearing, the right to contest any application for the appointment of a guardian for his or her person, estate, or both, and the right to be represented by counsel. ______________________ Date _______________________________________ Investigator PAGE 7 OF 7 S.P. FORM 17.8 – COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP 10/01/07 American LegalNet, Inc. www.FormsWorkflow.com