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 exploit