Statement Of Expert Evaluation Form. This is a Ohio form and can be use in Summit County (Court Of Common Pleas).
Tags: Statement Of Expert Evaluation, 17.1, Ohio County (Court Of Common Pleas), Summit
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. PROBATE COURT OF SUMMIT COUNTY, OHIO : GUARDIANSHIP OF: Plaintiff(s) CASE NO. -against- Calendar No. : JUDICIAL SUBPOENA : : STATEMENT OF EXPERT EVALUATION : Definition of Incompetent (R.C. 2111.01 (D)): “Incompetent means any person who is so mentally Defendant(s) : impaired .as .a .result. . . .a .physical. or .mental.illness .or. disability, or retardation, or as a result of chronic . . . . . . . . . . . of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 PEOPLE OF THE STATE OF NEW YORK The Statement of Evaluation does not declare the prospective ward competent or incompetent, but is TO 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 Applicant/Guardian. GREETINGS: 1. This Statement of Evaluation is for: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Guardianship Application. at be completed by a Licensed Physician or Licensed Clinical located (To County of in room Psychologist, and attached to the , 20 , on the day of , at o'clock in the noon, and at any recessed Application). or adjourned date, to testify and give evidence as a witness in this action on the part of the Guardian’s Report. (Evaluation and Statement by a Licensed Physician, Licensed Clinical Psychologist, Licensed Social Worker, or Mental Retardation Team to be completed within three months of date of the report. punishable as a contempt of Your failure to comply with this subpoena isR.C. 2111.49(A)(1)(i).) court and will make you liable to 2. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Statement completed by: result of your failure to comply. (Please type or print). Name Witness, Honorable Address Court in County, Phone , one of the Justices of the day of Who is a: Licensed Physician Licensed Social Worker 3. , 20 (Attorney must sign above and type name below) Licensed Clinical Psychologist Mental Retardation Team Attorney(s) for Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. Office and P.O. Address Form 17.1 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. CASE NO. ____________________________ : 4. Is the prospective ward mentally impaired? 5. A. Plaintiff(s) G Yes : Calendar No. G No JUDICIAL SUBPOENA Is there observed or reported evidence of mental impairment? -against: Yes No Describe: : B. 6. 7. : If reported, name source: Defendant(s) : ...................................................... If the prospective ward is mentally impaired, what is the cause? THE PEOPLE OF THE STATEor reported evidence of physical impairment? A. Is there observed OF NEW YORK Yes No Describe: TO B. If reported, name source: GREETINGS: 8. 9. Can the prospective ward conduct business excuses being laidthe aid of and each of you attend before WE COMMAND YOU, that all business and affairs without aside, you a guardian? Yes No Comments: at the , the Honorable Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or Can the prospective ward properly careafor himself without on the part of the adjourned date, to testify and give evidence as witness in this action the aid of a guardian? Yes 10. No Comments: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN’S REPORT) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a In of opinion, the guardianship should be: Continued resultmyyour failure to comply. Terminated 11. Witness, Honorable , one of the Justices of the (TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) Court in County, day of , 20 In my opinion, the application for guardianship: Should be granted Should not be granted (Attorney must sign above and type name below) ADDITIONAL COMMENTS Attorney(s) for I certify that I have evaluated of guardianship. Date of Evaluation Office and P.O. Address for the purpose Telephone No.: Facsimile No.: Evaluator E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com