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Examining Physicians Or Psychologists Report GN-3130 - Wisconsin
| Examining Physicians Or Psychologists Report Form. This is a Wisconsin form and can be used in Guardianship Circuit Court Statewide . |
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Examining Physician's or Psychologist's Report INSTRUCTIONS NOTE: This report will be used in a legal proceeding to determine if this individual is in need of a guardian or in need of protective placement or protective services. Prior to examining this individual, you must inform the individual of his/her rights. Those rights are contained in the statement below and should be read by you to the individual before you begin your examination. Please answer the questions to the best of your ability, to a reasonable degree of professional certainty. Any questions that you cannot answer should be marked "unknown." Type or print your answers neatly. You may supplement this report with attachments. STATEMENT TO BE READ TO THE INDIVIDUAL PRIOR TO EXAMINATION I have been asked to give a professional opinion about your need for a guardian and for protective placement or protective services. Before we begin, I must tell you: Things you say to me may be used to decide if you need a guardian. You have the right to refuse to participate in this evaluation, unless a court ordered you to participate. You have the right to refuse to speak with me. I am required to report to the Court even if you do not speak to me. What we discuss is not confidential and may be shared in Court. DEFINITIONS Developmentally Disabled: A disability attributable to intellectual disability, cerebral palsy, epilepsy, autism, or another neurological condition closely related to intellectual disability or requiring treatment similar to that required for individuals with intellectual disability, which has continued or can be expected to continue indefinitely, substantially impairs an individual from adequately providing for his or her own care or custody, and constitutes a substantial handicap to the afflicted individual. The term does not include dementia that is primarily caused by degenerative brain disorder. Serious and Persistent Mental Illness: A mental illness that is severe in degree and persistent in duration, that causes a substantially diminished level of functioning in the primary aspects of daily living and an inability to cope with the ordinary demands of life, that may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support that may be of lifelong duration. Serious and persistent mental illness includes schizophrenia as well as a wide spectrum of psychotic and other severely disabling psychiatric diagnostic categories, but does not include degenerative brain disorder or a primary diagnosis of a developmental disability or of alcohol or drug dependence. Degenerative Brain Disorder: The loss or dysfunction of an individual's brain cells to the extent that he or she is substantially impaired in his or her ability to provide adequately for his or her own care or custody or to manage adequately his or her property or financial affairs. Other Like Incapacities: Those conditions incurred at any age that are the result of accident, organic brain damage, mental or physical disability, or continued consumption or absorption of substances, and that produce a condition that substantially impairs an individual from providing for his or her own care or custody. Incapacity: Inability to effectively receive and evaluate information or to make or communicate a decision with respect to the exercise of a right or power. Impairment: Developmental disability, serious and persistent mental illness, degenerative brain disorder, or other like incapacities. Meet the Essential Requirements for Physical Health or Safety: Perform those actions necessary to provide the health care, food, shelter, clothes, personal hygiene, and other care without which serious physical injury or illness will likely occur. Protective Services: Services that when provided to an individual with developmental disabilities, degenerative brain disorder, serious and persistent mental illness, or other like incapacity, keep the individual safe from abuse, neglect, or misappropriation of property or prevent the individual from experiencing deterioration or from inflicting harm on himself/herself or another individual. (This Instruction Page should NOT be submitted to the Court) GN-3130, 03/12 Examining Physician's or Psychologist's Report §54.36, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material. DO NOT SUBMIT THIS PAGE TO THE COURT For Official Use STATE OF WISCONSIN, CIRCUIT COURT, Amended COUNTY IN THE MATTER OF Examining Physician's or Psychologist's Report Case No. Date of Birth Date of Examination: Place of Examination: Date of Birth: Children: Educational Background: Veteran Status: Occupation and Employment Status: Collateral sources used as part of your evaluation Records: Interviews with others: Other: Brief History: [Report relevant social and medical history] Age: Time spent with individual: Gender: Female Male Marital Status: EXAMINATION 1. A. Prior to beginning your evaluation of this individual, did you read to him/her the "STATEMENT TO BE READ TO THE INDIVIDUAL PRIOR TO EXAMINATION?" Yes No If no, Explain: B. Did the individual appear to understand? Yes No Comment: Check this box only if ALL of the following are true: A. This individual has suffered a sudden and catastrophic injury or illness and is presently unresponsive, unconscious, or comatose; AND B. His/her condition is likely to persist for the foreseeable future; AND C. It is not possible to interview or evaluate him/her; AND D. An alternate decision maker is required to provide for his or her proper care and treatment. (If #2. is checked, proceed directly to #10.) 3. Did the individual's presentation suggest sedation, intoxication, delirium or other condition affecting the individual's participation in the examination? Yes No Explain: A. Indicate your estimate of the individual's level of intelligence: B. Describe the individual's level of functional knowledge: (e.g. ability to read, use currency, phone, etc.) GN-3130, 03/12 Examining Physician's or Psychologist's Report §54.36, Wisconsin Statutes 2. 4. This form shall not be modified. It may be supplemented with additional material. Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Examining Physician's or Psychologist's Report Page 2 of 4 Case No. 5. Note level of impairment and describe examination findings in the following areas: Attention/Concentration Intact Mild Im
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