PROBATE COURT OF STARK COUNTY, OHIO IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. 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 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 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 Expert Evaluation is to be filed with or attached to: A. Guardianship Application: Completed by Licensed Physician or Psychologist prior to the filing and attached to the application. B. Guardian's Report: Completed by Licensed Physician Licensed Independent Social Worker Licensed Clinical Licensed Clinical Psychologist 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. 2. 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. 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: 17.1 STATEMENT OF EXPERT EVALUATION 6/1/06 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 4. Is the individual presently under medication? dosage, and purpose? Yes No If yes, what is the medication, 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, 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) Yes No Unknown b) Speech Yes No Unknown c) Motor Behavior Yes No Unknown d) Thought Process Yes No Unknown e) Affect Yes No Unknown f) Memory Yes No Unknown g) Concentration and comprehension Yes No Unknown h) 7. Orientation Judgment Yes No Unknown Please describe any impairments identified in question six. (Continue comments on page 4). Page 2 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 8. Is the individual physically impaired? 9. Are there any special characteristics of the individual which should be considered in evaluating the individual for guardianship? Yes Yes No No If yes: Description If yes: Explain 10. Are there any indications of abuse, neglect or exploitation of the individual? 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 Yes No No If no: Explain 12. Do you believe this individual is capable of managing the individual's finances and property? Yes 13. No If no: Explain Prognosis: A. B. 14. Is the condition stabilized? Yes Is the condition reversible? No Yes No 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 certainty, that the mental capacity of this ward will not improve. Date Signature - Licensed Physician/Clinical Psychologist Page 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ADDITIONAL COMMENTS Date Signature-Licensed Physician/Clinical Psychologist Page 4 American LegalNet, Inc. www.FormsWorkflow.com