Form PC-2.5 "Decision-Making Assessment Tool (For Limited Guardianship or Guardianship)" - Rhode Island

What Is Form PC-2.5?

This is a legal form that was released by the Rhode Island Probate Court - a government authority operating within Rhode Island. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the Rhode Island Probate Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PC-2.5 by clicking the link below or browse more documents and templates provided by the Rhode Island Probate Court.

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Download Form PC-2.5 "Decision-Making Assessment Tool (For Limited Guardianship or Guardianship)" - Rhode Island

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State of Rhode Island
DATE FILED
Probate Court
DECISION-MAKING ASSESSMENT TOOL
(FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP)
FOR
COURT USE ONLY
RIGL 33-15-4
&
RIGL 33-15-47
STATE OF RHODE ISLAND
Select County
County of
PROBATE COURT OF THE
Select City or Town
Estate of
City or Town of
Alias
No.
Name of Individual
Being Assessed
Current Street
Address
City/Town
State
Zip
Phone
Code
Number
Permanent Address (if different)
Street Address
City/Town
State
Zip
Phone
Code
Number
Instructions for Completion
This document will be used by a Probate Court to determine whether to appoint a guardian to assist
this individual in some or all areas of decision-making.
This document has two parts. Please first complete the part which is right after these instructions,
titled Assessment. Then complete the second section, titled Summary.
To a physician completing this document: The individual’s treating physician must complete
this document. If there is any information of which the treating physician does not have direct
knowledge, he or she is encouraged to make such inquiries of such other persons as are necessary
to complete the entire form. Those persons might include other medical personnel such as nurses, or
other persons such as family members or social service professionals who are acquainted with the
individual. If the physician has received information from others in completing this form, the names of
those individuals must be listed on the Summary.
To a non-physician completing this document: Professionals or other persons acquainted with the
individual being assessed may also complete this document. If there is information of which a non-
physician does not have knowledge, such non-physician may either leave portions of the document
blank, or also make inquiries or do such investigation as is necessary to complete the document.
Again, the names of any individual from whom information is derived should be listed on the Summary.
The document must be signed and dated by the person completing it. It does not need to be notarized.
PC-2.5 (Rev. 05/21)
Page 1 of 5
State of Rhode Island
DATE FILED
Probate Court
DECISION-MAKING ASSESSMENT TOOL
(FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP)
FOR
COURT USE ONLY
RIGL 33-15-4
&
RIGL 33-15-47
STATE OF RHODE ISLAND
Select County
County of
PROBATE COURT OF THE
Select City or Town
Estate of
City or Town of
Alias
No.
Name of Individual
Being Assessed
Current Street
Address
City/Town
State
Zip
Phone
Code
Number
Permanent Address (if different)
Street Address
City/Town
State
Zip
Phone
Code
Number
Instructions for Completion
This document will be used by a Probate Court to determine whether to appoint a guardian to assist
this individual in some or all areas of decision-making.
This document has two parts. Please first complete the part which is right after these instructions,
titled Assessment. Then complete the second section, titled Summary.
To a physician completing this document: The individual’s treating physician must complete
this document. If there is any information of which the treating physician does not have direct
knowledge, he or she is encouraged to make such inquiries of such other persons as are necessary
to complete the entire form. Those persons might include other medical personnel such as nurses, or
other persons such as family members or social service professionals who are acquainted with the
individual. If the physician has received information from others in completing this form, the names of
those individuals must be listed on the Summary.
To a non-physician completing this document: Professionals or other persons acquainted with the
individual being assessed may also complete this document. If there is information of which a non-
physician does not have knowledge, such non-physician may either leave portions of the document
blank, or also make inquiries or do such investigation as is necessary to complete the document.
Again, the names of any individual from whom information is derived should be listed on the Summary.
The document must be signed and dated by the person completing it. It does not need to be notarized.
PC-2.5 (Rev. 05/21)
Page 1 of 5
A. BIOLOGICAL ASSESSMENT
THE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON (DATE):
1. DIAGNOSIS and PROGNOSIS:
2. MEDICATIONS (PLEASE LIST):
How do the above medications, if any, affect the individual’s decision-making ability? Please explain:
3. CURRENT NUTRITIONAL STATUS:
PC-2.5 (Rev. 05/21)
Page 2 of 5
B. PSYCHOLOGICAL ASSESSMENT
1. MEMORY (CHECK ONE):
3. JUDGEMENT (CHECK ONE):
A. Intact
A. Intact
B. Mild Impairment
B. Able to Make Most Decisions
C. Moderate Impairment
C. Impaired
D. Severe Impairment
D. Gross Impairment
2. ATTENTION (CHECK ONE):
4. LANGUAGE (CHECK ONE):
A. Intact
A. Intact
B. Mild Impairment
B. Sensory Deficits: Hearing/Speech/Sight
C. Shifting/Wandering
C. Impairment in Comprehension/Speech Mild/Moderate/
Severe
D. Delirium
D. Completely Unresponsive
E. Unresponsive
5. EMOTION (CHECK ALL THAT APPLY):
A. ANXIETY/DEPRESSION
B. OTHER
1. None
1. Suspiciousness/Belligerence/Explosiveness
2. History of Anxiety/Depression
2. Delusions/Hallucinations
3. Moderate Symptoms of Anxiety/Depression
3. Unresponsive
4. Severe Symptoms with Sleep/Appetite/Energy
Disturbance
5. Suicidal/Homicidal
If you checked any of the above, other than “A” or “1” for any of the above categories, please explain whether the situation is treatable or
reversible, and if so, how:
PC-2.5 (Rev. 05/21)
Page 3 of 5
C. SOCIAL ASSESSMENT
1. MOBILITY (CHECK ALL THAT APPLY):
A. Intact/Exercises
B. Drives Car or Uses Public Transportation
C. Independent Ambulation in Home Only
D. Walker/Cane
E. Requires Assistance
If you checked “C,” “D,” or “E,” is situation treatable or reversible? If so, how?
2. SELF CARE (CHECK ALL THAT APPLY):
A. No Assistance Required
B. Requires Assistance with:
1. Meals
2. Bathing
3. Dressing
4. Toileting/Feeding
If you checked any choices under “B,” is individual aware that assistance is required?
Is individual willing to accept assistance?
Is individual able to arrange for assistance?
3. CARE PLAN MAINTENANCE (CHECK ALL THAT APPLY):
A. No Active Problem
D. Passively Cooperative
B. Initiates Problem Identification
E. Passively Uncooperative
C. Actively Cooperative
F. Actively Uncooperative
4. SOCIAL NETWORK RELATIONSHIPS (CHECK ONE IN “A” AND ONE IN “B”):
A. SUPPORT
B. SOCIAL SKILLS
1. Very Good Supportive Network
1. Very Good Social Skills
2. Some Support from Family & Friends
2. Good Social Skills
3. No or Limited Support from Family & Friends
3. Interacts with Prompting
4. Needs Community Support
4. Isolated
5. Isolated/Homebound
PC-2.5 (Rev. 05/21)
Page 4 of 5
D. SUMMARY
I hereby certify that I have reviewed Sections A, B, and C attached hereto and based on such assessments that the individual’s
decision-making ability is as follows:
1. Please describe as fully as you can the individual’s decision-making ability in each of the following areas:
A. FINANCIAL MATTERS:
B. HEALTH CARE MATTERS:
C. RELATIONSHIPS:
D. RESIDENTIAL MATTERS:
2. Please indicate your opinion regarding whether the individual needs a substitute decision-maker in any of the following areas (Check
one for each category. If you check “limited” for any category, please explain.):
Yes
No
Limited
A. FINANCIAL MATTERS
Yes
No
Limited
B. HEALTH CARE MATTERS
Yes
No
Limited
C. RELATIONSHIPS
Yes
No
Limited
D. RESIDENTIAL MATTERS
E. OTHER: (if there are other areas in which you think the individual lacks decision-making ability or has limited decision-making
ability, please explain)
Name of
Title
Physician
(Print or Type)
Signature
Date
Name of
Title
Non-Physician
(Print or Type)
Signature
Date
Names and titles of other who assisted in preparation of this Assessment:
Name
Title
PC-2.5 (Rev. 05/21)
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