Court Disclaimer:Use of this form may not be appropriate in all instances. If extra space is required for any answers,please provide extra answer sheets. Please staple any additional answer sheets or supplementalmaterials directly to this written deposition.Probate Section Comment:The Court has agreed to allow written depositions in the posted form in lieu of live medicaltestimony in guardianship proceedings when the issue of capacity is uncontested. Despiteauthorization to use this form, counsel are cautioned to exercise judgment in determining whetherthe written deposition is appropriate in a particular case, where additional testimony may bewarranted by the facts involved. A written deposition is not generally appropriate for emergencyguardianships, because of the need for additional testimony about the emergency medical treatmentneeded and the alternatives to treatment.In addition, the Court should not be expected to review handwritten answers; as a courtesy, counselshould have the deposition answers typed and then returned to the physician for signature andnotarization. American LegalNet, Inc. www.FormsWorkFlow.com 1IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTYFIRST JUDICIAL DISTRICT OF PENNSYLVANIAORPHANS222 COURT DIVISIONO. C. NO. of AI In Re: , AN ALLEGED INCAPACITATED PERSONWRITTEN DEPOSITION PURSUANT TO 20 PA.C.S. 247 5518Written Deposition of Dr. Q.Please state your name and your office address.A.Q.Please state your educational background including the schools you have attended, theacademic and professional degrees you have received, and the dates you received thesedegrees.A. American LegalNet, Inc. www.FormsWorkFlow.com 2Q.What is your current position?A.Q.How long have you practiced your profession and how long have you held your currentposition?A.Q.State the names of the Pennsylvania professional licensing agencies that have issued licensesto you? Include the date of issuance of such licenses and whether they are still current. (Inconjunction with this question, please attach a copy of your curriculum vitae.)A. American LegalNet, Inc. www.FormsWorkFlow.com 3Q.Have you ever testified as a witness in a court proceeding, either in person or by deposition?A. Q.What is the age and date of birth of the alleged incapacitated person?A.Q.Have you ever examined, interviewed or tested the alleged incapacitated person?A.Q.Was a mini-mental status test performed, and if so, what was the result?A. American LegalNet, Inc. www.FormsWorkFlow.com 4Q.If so, on what dates did you have an opportunity to examine, interview or test the allegedincapacitated person?A.Q.Please explain the nature of the examinations referred to in the previous three questions.You may attach any written reports if necessary.A.Q.Have you regularly treated the alleged incapacitated person, and if so, for how long?A. American LegalNet, Inc. www.FormsWorkFlow.com 5Q. Please state your diagnosis of the patient, including the nature and extent of thesubject's incapacities and disabilities and his/her mental, emotional and physical condition.A.Q.Please explain how these incapacities and/or disabilities manifest themselves in the subject222sadaptive behavior and social skills?A.Q.In your opinion, is the alleged incapacitated person222s ability to receive and evaluateinformation effectively and communicate decisions in any way significantly impaired?A. American LegalNet, Inc. www.FormsWorkFlow.com 6Q.If you answered yes to the previous question, does the impairment render the allegedincapacitated person partially or totally unable to manage his/her financial resources or tomeet essential requirements for his/her physical health and safety?A.Q.What services are being utilized to meet the essential requirements for the subject222s physicalhealth and safety?A.Q.What services are being utilized to manage the subject222s financial resources?A. American LegalNet, Inc. www.FormsWorkFlow.com 7Q.Which methods/techniques, if any, are being utilized to help develop and/or regain thealleged incapacitated person222s abilities?A.Q.What kind of assistance does the subject require?A.Q.Are there any appropriate less restrictive alternatives? If so, please elaborate. If not, pleaseexplain why.A. American LegalNet, Inc. www.FormsWorkFlow.com 8Q.What is the probability that the extent of his/her incapacities may significantly increase ordecrease? Please include an explanation.A.Q.Would the alleged incapacitated person222s physical or mental condition be harmed by thesubject222s presence at the hearing on the subject222s alleged incapacity? If so, please includean explanation.A.Q.Is there any other information relevant to your diagnosis that could assist the Court in itsdetermination of capacity?A.Dated: Signed: American LegalNet, Inc. www.FormsWorkFlow.com 9COMMONWEALTH OF PENNSYLVANIA::SSCOUNTY OF:being duly sworn according to law, deposes and says that theanswers set forth in this forgoing deposition are true and correct to the best of his/her knowledge,information or belief.SWORN TO AND SUBSCRIBEDbefore me this day of , 20Notary Public American LegalNet, Inc. www.FormsWorkFlow.com 1020 Pa.C.S. (Current through End of the 2001 Regular Session)247 5518. Evidence of incapacity.To establish incapacity, the petitioner must present testimony, in person or by deposition fromindividuals qualified by training and experience in evaluating individuals with incapacities of thetype alleged by the petitioner, which establishes the nature and extent of the alleged incapacities anddisabilities and the person's mental, emotional and physical condition, adaptive behavior and socialskills. The petition must also present evidence regarding the services being utilized to meet essentialrequirements for the alleged incapacitated person's physical health and safety, to manage the person'sfinancial resources or to develop or regain the person's abilities; evidence regarding the types ofassistance required by the person and as to why no less restrictive alternatives would be appropriate;and evidence regarding the probability that the extent of the person's incapacities may significantlylessen or change.247 5518.1. Cross-examination of witnesses.Testimony as to the capacity of the alleged incapacitated person shall be subject to cross-examinationby counsel for the alleged incapacitated person. American LegalNet, Inc. www.FormsWorkFlow.com