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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 Guardianships Probate Cuyahoga County (Court Of Common Pleas) . |
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Probate Court of Cuyahoga County, Ohio John J. Donnelly, Presiding Judge John E. Corrigan, Judge IN THE MATTER OF THE GUARDIANSHIP OF _______________________________________ CASE NUMBER: ______________________________________ STATEMENT OF EXPERT EVALUATION Definition of Incompetent (R.C. 2111.03(D)): Incompetent means any person who is so mentally impaired as a result of aphysical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking propercare 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 anyperson 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 beconsidered by the Court. The fee for completing the evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from theapplicant/guardian.. 1. This Statement of Evaluation is for: ____ Guardianship Application. (To be completed by a licensed Physician or Licensed Clinical Psychologist. And attachedto the Application ____ Guardians Report. (Evaluation and Statement by a licensed Physician, Licensed Clinical Psychologist, Licensed SocialWorker, 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) Name __________________________________________________________________________________________ Address ________________________________________________ Phone __________________________________ Who is a: ______ Licensed Physician ______ Licensed Clinical Psychologist ______ Licensed Social Worker ______ Mental Retardation Team3. 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes ________ No ______ Form 17.1 - Statement of expert Evaluation<<<<<<<<<********>>>>>>>>>>>>> 25. A. Is there observed or reported evidence of mental impairment? Yes _____ No _____ Describe: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ B. If reported, Name source : _________________________________________________________________________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 care for himself without the aid of a guardian? Yes _____ No _____ Comments: ____________________________________________________________________________________________________________________________________________________________________10. (TO BE COMPLETED IF SUBMITTED WITH A GUARDIANS 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
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