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Statement Of Expert Evaluation 17.1 - Ohio

Statement Of Expert Evaluation Form. This is a Ohio form and can be used in Guardianship Probate Summit County (Court Of Common Pleas) .
 Fillable pdf Last Modified 1/16/2014
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PROBATE COURT OF SUMMIT COUNTY, OHIO GUARDIANSHIP OF _________________________________________________________ CASE NO.___________________________ STATEMENT OF EXPERT EVALUATION Definition of Incompetent (R.C. 2111.01 (D)): "Incompetent means any person who is so mentally impaired as a result of a physical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide for his family or other persons for whom he is charged by law to provide, or any person confined to a penal institution within this State." The Statement of Evaluation does not declare the prospective ward competent or incompetent, but is evidence to be considered by the Court. The fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant/Guardian. 1. This Statement of Evaluation is for: Guardianship Application. (To be completed by a Licensed Physician or Licensed Clinical Psychologist, and attached to the Application). Guardian's Report. (Evaluation and Statement by a Licensed Physician, Licensed Clinical Psychologist, Licensed Social Worker, or Mental Retardation Team to be completed within three months of date of the report. R.C. 2111.49(A)(1)(i).) 2. Statement completed by: (Please type or print full name and address). Name: ________________________________________ Address: ________________________________________ Phone: ________________________________________ Who is a: Licensed Physician Licensed Social Worker Licensed Clinical Psychologist Mental Retardation Team 3. Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4. Is the prospective ward mentally impaired? 5. A. Yes No Yes No Is there observed or reported evidence of mental impairment? Describe:_______________________________________________________________ __________________________________________________________________________ B. Form 17.1 If reported, name source:______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. If the prospective ward is mentally impaired, what is the cause?_____________________ _______________________________________________________________________ 7. A. Is there observed or reported evidence of physical impairment? Yes No Describe:_______________________________________ __________________________________________________________________ B. If reported, name source:______________________________________________ 8. Can the prospective ward conduct business affairs without the aid of a guardian? Yes No Comments:______________________________________ _______________________________________________________________________ 9. Can the prospective ward properly care for him/herself without the aid of a guardian? Yes No Comments:______________________________________ _______________________________________________________________________ 10. (TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be: Continued _________ Terminated _________ 11. (TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) In my opinion, the application for guardianship: Should be granted Should not be granted _________ _________ ADDITIONAL COMMENTS __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ I certify that I have evaluated _________________________ for the purpose of guardianship. ______________________________ Date of Evaluation _______________________________ Evaluator's signature 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 not improve. ___________________________________ Date ________________________________________ Signature-Licensed Physician/Clinical Psychologist American LegalNet, Inc. www.FormsWorkFlow.com
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