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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 Statewide . |
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PROBATE COURT OF IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. COUNTY, OHIO STATEMENT OF EXPERT EVALUATION Definition of incompetent [ O.R.C. 2111.01 (D)): "Incompetent means any person who is so mentally impaired as a result of a mental or physical illness or disability, or mental retardation, or as a result of chronic substance abuse, that the person is incapable of taking proper care of the person's self or property or fails to provide for the person's family or other persons for whom the person is charged by law to provide , or any person confined to a correctional 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. 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 thre months of date of the report. R.C. 2111.49(A)(1)(i).) Statement completed by: (please type or print) Name:________________________________________________________________________ Address:______________________________ Phone _________________________________ Who is a: _______ Licensed Physician _______ Licensed Social Worker 3. _______ Licensed Clinical Psychologist _______ Mental Retardation Team 2. 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 1/1/98 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ________________________________________________________________________________ ________________________________________________________________________________ 4. 5. Is the prospective ward mentally impaired? A. Is there observed or reported evidence of mental impairment? Yes ________ No ________ Describe: ________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ B. If reported, name source: _______________________________________________________ 6. 7. If the prospective ward is mentally impaired, what is the cause? ___________________________ 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. 11. (TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be: Continued ________ Terminated ________ (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 FORM 17.1 STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkflow.com Yes _______ No_______
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