"Statement of Expert Evaluation Form" - Warren County, Ohio

This Ohio-specific printable "Statement of Expert Evaluation Form" is a part of the legal paperwork issued by the Ohio Judicial System.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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PROBATE COURT OF WARREN COUNTY, OHIO
IN THE MATTER OF 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
mental pr 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 that 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 filling and attached to the application.
B.
Guardian’s Report: Completed by
Licensed Physician
Licensed Clinical Psychologist
Licensed Independent Social Worker
Licensed Professional Clinical Counselor or
Mental Retardation Team.
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 a person: a Licensed Physician shall complete
the Supplement for Emergency Guardian, form 17.1A with specificity indication 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
PROBATE COURT OF WARREN COUNTY, OHIO
IN THE MATTER OF 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
mental pr 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 that 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 filling and attached to the application.
B.
Guardian’s Report: Completed by
Licensed Physician
Licensed Clinical Psychologist
Licensed Independent Social Worker
Licensed Professional Clinical Counselor or
Mental Retardation Team.
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 a person: a Licensed Physician shall complete
the Supplement for Emergency Guardian, form 17.1A with specificity indication 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
CASE NO. ___________________________
4.
Is the individual presently under medication?
Yes
No
If yes, what is the medication, dosage,
and purpose? _______________________________________________________________________________
__________________________________________________________________________________________
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 ___________________________________________________________________
___________________________________________________________________________________________
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
Yes
No
Unknown
b.
Speech
Yes
No
Unknown
c.
Motor Behavior
Yes
No
Unknown
d.
Thought Process
Yes
No
Unknown
e.
Affect
Yes
No
Unknown
f.
Memory
Yes
No
Unknown
g.
Concentration and comprehension
Yes
No
Unknown
h.
Judgment
Yes
No
Unknown
7.
Please describe any impairment identified in question six. (Continue commonest on page 4).
___________________________________________________________________________________________
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.
Is the condition stabilized?
Yes
No
B.
Is the condition reversible:
Yes
No
14.
In my opinion a guardianship should be:
Established/Continued
Denied/Terminated
I certify that I have evaluated the individual on ________________________________________________, 20 _________
Date: _____________________________________
_______________________________________________
Signature of Evaluator
GUARDIAN’S REPORT ADDENDUM
(Not to be used with initial Application)
It is my opinion, based upon a reasonable degree of medical or psychological certainty, that the mental capacity of
this ward will no improve.
___________________________________
________________________________________
Date
Signature – Licensed Physician/Clinical Psychologist
CASE NO. ___________________________
ADDITIONAL COMMENTS
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date ______________________________________
_______________________________________________
Signature – Licensed Physician/Clinical Psychologist
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