PROBATE COURT OF ________________ 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 Licensed Clinical Psychologist prior to the filing and attached to the application. B. Guardian's Report: Completed by Licensed Physician Licensed Clinical Psychologist Licensed Independent Social Worker Mental Retardation Team. Licensed Professional Clinical Counselor or The evaluation or examination shall be completed within three months prior to the date of the Report. R.C. 2111.49 C. 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. 2. 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 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO._______________________ 4. Is the individual presently under medication? and purpose? Yes No If yes, what is the medication, dosage, ________________________________________________________________________________ ___________________________________________________________________________________________ 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) Orientation b) Speech c) Motor Behavior d) Thought Process e) Affect f) Memory g) Concentration and comprehension h) Judgment Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown 7. Please describe any impairments identified in question six. (Continue comments on page 4). ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com CASE NO._______________________ 8. Is the individual physically impaired? Yes No If yes: Description ___________________________________________________________________________________________ 9. Are there any special characteristics of the individual which should be considered in evaluating the individual for guardianship: Yes No If yes: Explain ___________________________________________________________________________________________ ___________________________________________________________________________________________ 10. Are there any indication of abuse, neglect or exploitation of the individual? Yes No 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 No If no: Explain _______________________________________________________________________________ 12 Do you believe this individual is capable of managing the individual's finances and property? Yes No If no: Explain ___________________________________________________________________________________________ 13. Prognosis: A. B. 14. Is the condition stabilized? Is the condition reversible: Yes Yes No No In my opinion a guardianship should be: Established/Continued Denied/Terminated I certify that I have evaluated the individual on ______________________________________________, 20 __________. Date: _____________________________________ _________________