1 2 3 4 5 6 7 8 9 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING 10 In the Guardianship of: 11 ______________________________, 12 13 14 An Alleged Incapacitated Person. ) Case No.: ) ) MEDICAL/PSYCHOLOGICAL ) REPORT ) (MDR) 15 This form is required by Washington state law for all Guardianships. Your assistance in completing this form on or before ______________________________ is appreciated. 16 (Please type or print clearly.) 17 18 I have been chosen by the Guardian ad Litem in the above matter to examine and interview ______________________________, and I submit the following report: 19 My name, title, address, telephone number are as follows: 20 _______________________________________________________________________. 21 A. My education and experiences that are pertinent to the type of disorder or incapacity 22 involved in this case: (a resume/curriculum vitae may be attached.). 23 24 25 26 ________________________________________________________________________ B. Date of most recent examination of the Alleged Incapacitated Person (most recent exam must be within 30 days of date of this request): ____________________________ C. A summary of the relevant medical functional, neurological, psychological, or psychiatric history of the Alleged Incapacitated Person as known to me: MEDICAL/PSYCHOLOGICAL REPORT- 1 12/2005 GUARDIANSHIP REPORT American LegalNet, Inc. www.USCourtForms.com 1 D. My findings regarding the Alleged Incapacitated Person’s capacity to manage personal 2 or financial matters are: ______________________________________. 3 E. The following medication(s) are currently prescribed to the Alleged Incapacitated 4 5 6 Person for the following condition(s). Medication: _____________________ Condition: _____________________ Medication: _____________________ Condition: _____________________ Medication: _____________________ Condition: _____________________ 7 F. The effect of these current medications on the Alleged Incapacitated Person’s ability to 8 understand or participate in the Guardianship proceedings is: 9 _______________________________________________________________________. 10 11 12 13 G. My opinion as to the specific assistance the Alleged Incapacitated Person needs (including items such as household chores, managing finances): _______________________________________________________________________. H. I have also met or spoken with the following individuals regarding the Alleged Incapacitated Person: _____________________________________________________. 14 15 16 17 I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. Signed at ________________, Washington, ___________, ____200__. 18 19 20 Signature Printed Name Address Telephone/Fax Number City, State, Zip Code Email Address 21 22 23 24 25 26 MEDICAL/PSYCHOLOGICAL REPORT- 2 12/2005 GUARDIANSHIP REPORT American LegalNet, Inc. www.USCourtForms.com