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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 Wood County (Court Of Common Pleas) . |
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PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the GUARDIANSHIP of:_______________________________________________________ Case No._______________________ Date:________________________ 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) Name _______________________________________________________________________________ Address ___________________________________________________ Phone ______________________ Who is a : _____ _____ 3. Licensed Physician Licensed Social Worker _____ _____ Licensed Clinical Psychologist Mental Retardation Team Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. FORM 17.1 - STATEMENT OF EXPERT EVALUATION Crensch$\forms\17.1 7/26/01 American LegalNet, Inc. www.USCourtForms.com 4. 5. Is the prospective ward mentally impaired? A. Is there observed or reported evidence of mental impairment? Yes ______ Yes ______ No_____ 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 properly care for himself 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: ___________________________________ American LegalNet, Inc. www.USCourtForms.com
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