PROBATE COURT OF COUNTY, OHIO , 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:________________________________________________________________________ 17.8 - COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 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:________________ Others 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: _______________________________________________________ 2 17.8 Court Investigators Report on Proposed Guardianship Eff. Date October 1, 2007 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 1. Eating 2. Dressing 3. Transfer from bed 4. Toileting 5. Bathing 3 Unable to Determine 17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com CASE NO._____________ 6. Handling personal finances 7. Shopping 8. Driving 9. Meal preparation 10. Doing housework 11. Using telephone 12. Taking medications Explain further if necessary: ________________________________________________________________________ _______________________________________________________________________. IV. Additional Items Affecting Guardianship Plan Development A. Are there any indications or allegations of substance abuse by the individual or significant others 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 make recommendations: _________________________________ _______________________________________________________________________________ ______________________________________________________________________________. 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: ______________________________________________________________________________ ______________________________________________________________________________. 4 17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 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 mediation 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 5 No 17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 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: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6 17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 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 7 __________________________________________ Investigator 17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP Eff. Date October 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com