COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)GUIDELINES FOR PHYSICIAN REPORTINSTRUCTIONS TO PETITIONER: Fill in the information below and give this document to the court-appointed physician immediately after the ORDER APPOINTING PHYSICIAN is signed. Be sure a written report from the physician is given to everyone listed in the ORDER APPOINTING A PHYSICIAN no later than 10 days before the scheduled hearing. COURT CASE NUMBER:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PBTHE PEOPLE OF THE STATE OF NEW YORK TONAME OF PHYSICIAN: NAME OF PATIENT:(This is the person whom the Petitioner says needs a guardian and/or conservator)NAME OF PETITIONER: PETITIONER'S TELEPHONE NUMBER: DATE AND TIME OF COURT HEARING:GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,INSTRUCTIONS TO PHYSICIAN: A court case has been filed that asks the court to appoint a guardian and/or conservator for the person named above. Before the court grants such a petition, the court must decide if mental, physical, or other cause exists which necessitates a guardianship or conservatorship. Therefore, the court needs to know what you, as the physician for the person, think about the person's health, whether the person needs inpatient mental health treatment, and whether the person's driving privileges should be suspended. The court's goal is to do all that is possible to help the person about whom this case is pending to live as fully as his or her mental or physical impairments allow. The court realizes that your time is valuable, and has developed the following questions to make it easier for you to prepare your report. If you want to use some other format to submit your report, please feel free to do that too, so long as you provide the same type of information the court needs. If the Petitioner is seeking the authority to consent to inpatient mental health treatment, this report must be signed by a licensed psychiatrist or psychologist. After you complete the report, give the original report to the Petitioner and he or she will see to it that necessary copies are properly distributed. Please do not file your report with the Clerk of the Court. PLEASE DATE AND SIGN YOUR REPORT. THANK YOU FOR YOUR TIME AND ASSISTANCE. QUESTIONS FOR PHYSICIAN TO ANSWER: 1.(Attorney must sign above and type name below)What is the date you last saw your patient 2.How long have you been his or her physician? 3.Attorney(s) forWhy were you asked to do this evaluation? You have been the person's physician for many years You were asked to do so by the family An attorney selected you Your office is close to the person's residence You are the doctor for the person's nursing homeOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:© Superior Court of Arizona in Maricopa CountyPBGCA15f June 11, 2002Use only most current version ALL RIGHTS RESERVEDPage 1 of 4Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Other (please explain)4.What is your area of specialty? Are you Board Certified in this area?YesNo In any other area?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.Does the person appear to be having difficulty in any of the following areas? Mental disorder Physical illness Chronic intoxication or drug use Cognitive abilities Anything elseTHE PEOPLE OF THE STATE OF NEW YORK TO6.If the person is having difficulty, please specify the nature of the illness, disorder, etc. (include the person's diagnosis)GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of7.Has the person been treated or hospitalized before for this difficulty?YesNo If yes, when and where?o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room8.Is the person able to do the following things? If the person is able, please check each applicable box. Pay his or her bills Obtain food Provide adequate housing Perform daily self-help skills Live alone Take medication appropriately Drive a motor vehicle Make appropriate judgments that will protect him or her personally, physically, or financially If you believe the person is still able to drive a motor vehicle, but is in need of the assistance of a guardian, please explain why the person should be allowed to keep driving:Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) for9.If the person is currently on medication, please list them.Office and P.O. Address10Do you believe that the medication is affecting the person's ability to respond coherently?NoYesTelephone No.: Facsimile No.: E-Mail Address:NoYes11.Do you believe that the medication is affecting the person's ability to ambulate?© Superior Court of Arizona in Maricopa CountyPBGCA15f June 11, 2002Use only most current version ALL RIGHTS RESERVEDPage 2 of 4Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JU
|
Get this form for FREE as a print-only pdf
