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Examining Physicians Or Psychologists Report - Wisconsin
| Examining Physicians Or Psychologists Report Form. This is a Wisconsin form and can be used in Probate And Guardianship Dane Local County . |
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STATE OF WISCONSIN PROBATE COURT DANE COUNTY In re the Guardianship and Protective Placement of: _____________________________________ Alleged Incompetent Case No.: _______________ EXAMINING PHYSICIAN'S / PSYCHOLOGIST'S REPORT TO THE COURT: I certify that I have, by personal examination and inquiry, satisfied myself as to the condition of competency of this individual and the result of the evaluation and inquiry will be found in my answers to the following questions, which are true to the best of my knowledge. _______________________________________ Signature _______________________________________ Name Typed or Printed _______________________________________ Date Date(s) of evaluation: ______________________________________ Place(s) of evaluation: ______________________________________ Time spent with subject: ____________________________________ 1. If this evaluation was ordered by the court or done in preparation for a court hearing, did you Yes No inform the subject as to the nature of and the reasons for the evaluation? 2. If this evaluation was done expressly for guardianship and/or protective placement purposes, did you so inform the subject and indicate that he or she had a right to remain silent? Yes No If the evaluation was done prior to consideration of guardianship and/or protective placement, did the subject or his or her agent (e.g., a close relative or friend) give express permission to give the evaluation to the court? Yes No 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Is the subject presently under medication? Yes No If so, what is the medication and dosage? (Attach addenda if needed) 4. During the examination. did you notice a disturbance of the subject's: a. Orientation? Yes No b. Speech? Yes No c. Motor behavior? Yes No Yes No d. Thought processes? e. Affect? Yes No f. Memory? Yes No Yes No g. Concentration & comprehension? h. Judgment? Yes No 5. Please describe any abnormalities identified in question 4. (Attach addenda if needed) 6. Based on your evaluation, were you able to reach a conclusion as to the subject's ability to distinguish time and place? Yes No 7. Were the subject's responses coherent and logical? Yes No 8. Did you consult any collateral information in conjunction with your evaluation? Yes No Explain: 9. Please give a summary of background/historical information obtained from the subject and/or collateral: 2 American LegalNet, Inc. www.FormsWorkFlow.com 10. Could you determine the subject's general level of intelligence and fund of knowledge? Yes No Explain: 11. Do you believe that the subject in his or her present condition is substantially capable of managing h is or her property? Yes No Explain: l2.. Do you believe that the subject in his or her present condition is substantially capable of caring for himself: or herself? Yes No Explain: 13. What is your opinion of the subject's competency? 14. Do you believe that the subject of this proceeding is suffering from developmental disabilities, infirmities of aging, or other like incapacities? See below for definitions* Yes No Explain: -----------*"Developmentally disabled person" means any individual having a disability attributable to mental retardation, cerebral palsy, epilepsy, autism or another neurological condition closely related to mental retardation or requiring treatment similar to that required for mentally retarded individuals, which has continued or can be expected to continue indefinitely, substantially impairs the individual from adequately providing for his or her own care or custody and constitutes a substantial handicap to the afflicted individual. The term does not include a person affected by senility which is primarily caused by the process or aging or the infirmities of aging. Wis. St. § 880.01(2) "Infirmities of aging" means organic brain damage caused by advanced age or other physical degeneration in connection therewith to the extent that the person so afflicted is substantially impaired in his or her ability to adequately provide for his or her own care or custody. Wis. Stat. § 880.01 (5) "Other like incapacities" means those conditions incurred at any age which are the result of accident, organic brain damage, mental or physical disability, continued consumption or absorption of substances, producing a condition which substantially impairs an individual from providing for the individual's own care or custody. Wis. Stat. § 880.01 (8). 3 American LegalNet, Inc. www.FormsWorkFlow.com 15. As a result of developmental disabilities, infirmities of aging, or other like incapacities, do you feel the subject has a primary need for residential care and custody, and is so totally incapable of providing for his or her own care and custody that his or her condition creates a substantial risk of serious harm to himself or herself or others? Yes No Explain: 16. Do you recommend that the subject be protectively placed? Yes No If so, consider the following portion of the law relating to protective placement: ... Placement shall be made in the least restrictive environment consistent with the needs of the person to be placed. Factors to be considered in making protective placement shall include the needs of the person to be protected for health, social or rehabilitative services and the level of supervision needed ... Wis. Stat. § 55.06(9)(a). What type of facility would you recommend for placement? Nursing Home Adult Family Home CBRF Other ___________________________________________________________________ 17. How long do you believe the subject's condition will continue? 18. Are there any other comments you feel are important in evaluating the subject's need for a guardianship and protective placement? 4 American LegalNet, Inc. www.FormsWorkFlow.com
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