(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO. __________________________ ____________________________________ MEDICAL/PSYCHOLOGICAL REPORT (MDR) This form is required by Washington state law for all Guardianships. Your assistance in completing this form on or before ____________________ is appreciated. (Please type or print clearly.) I have been chosen by the Guardian ad Litem in the above matter to examine and interview ________________________________, and I submit the following report: ___________________________________________________________________________. A. My name, title, address, telephone number are as follows:___________________________ ____________________________________________________________________________. B. My education and experiences that are pertinent to the type of disorder or incapacity involved in this case are as follows: (a resume/curriculum vitae may be attached.) __________________ _____________________________________________________________________________. C. Date of most recent examination of the Alleged Incapacitated Person (most recent exam must be within 30 days of date of this request): ___________________________________________. #06-MEDICAL/PSYCHOLOGICAL REPORT PAGE 1 OF 3 Revised 2/07 American LegalNet, Inc. www.FormsWorkflow.com D. A summary of the relevant medical, functional, neurological, psychological, or psychiatric history of the Alleged Incapacitated Person as known to me is as follows: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ E. My findings as to the Alleged Incapacitated Person as it relates to capacity to manage personal or financial matters are: ___________________________________________________ _____________________________________________________________________________. F. The following medication(s) are currently prescribed to the Alleged Incapacitated Person for the following condition(s). Medication: _____________________ Condition: _________________________ Medication: ______________________ Condition: _________________________ Medication: ______________________ Condition: _________________________ G. The effect of these current medications on the Alleged Incapacitated Person’s ability to understand or participate in the Guardianship proceedings is: ___________________________ ____________________________________________________________________________ ____________________________________________________________________________. H. My opinion as to the specific assistance the Alleged Incapacitated Person needs is (including items such as household chores, managing finances): _________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________. I. I have also met or spoken with the following individuals regarding the Alleged Incapacitated Person: _______________________________________________________________________ ______________________________________________________________________________ #06-MEDICAL/PSYCHOLOGICAL REPORT PAGE 2 OF 3 Revised 2/07 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ ______________________________________________________________________________ I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. SIGNED AT ____________, WASHINGTON THIS ______ DAY OF _________, 20______ Signature of Physician/Psychologist/ Advanced Registered Nurse Practitioner Printed Name of Physician/Psychologist/ Advanced Registered Nurse Practitioner Address City, State, Zip Code Telephone/Fax Number Email Address #06-MEDICAL/PSYCHOLOGICAL REPORT PAGE 3 OF 3 Revised 2/07 American LegalNet, Inc. www.FormsWorkflow.com