Examination Report To Determine Capacity {3-17}

F.C.A. §§301.2, 322.1 F.C.A. Form 3-17 (Juvenile Delinquency­ Examination Report to Determine Capacity) 6/2016 ____________________________________________ In the Matter of Docket No. A Person Alleged to be a Juvenile Delinquent EXAMINATION REPORT. (To Determine Capacity) Respondent. ____________________________________________ TO THE FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF a duly " qualified psychiatrist " certified psychologist) hereby reports as follows: 1. I examined , , the Respondent herein, pursuant to an order of the Court, dated , to determine whether Respondent is " mentally ill " intellectually disabled on (date): at (location): on (date): at (location): 2.Based upon the above examination(s), in-my professional judgment, " is " is not an incapacitated person as defined in subdivision (13) of section 301.2 of the Family Court Act. *3. I base this opinion upon the following a. Diagnosis b. Prognosis *(Note to examiner) If a finding of incapacity is made, you must complete items 3 and 4 of this form. American LegalNet, Inc. www.FormsWorkFlow.com Form 3-17 *4. The following is a detailed statement of the reasons for my opinion: [Make particular reference to those aspects of the proceedings wherein Respondent lacks capacity to understand or to assist in defense.] Page 2 Dated: Signature **(Qualified Psychiatrist) **(Certified Psychologist) *Applicable if report finds Respondent to be an incapacitated person. Strike out one. American LegalNet, Inc. www.FormsWorkFlow.com