Release For DCF Background Check

Ward Name: Case Number: Annual Physician's Report of Examination (All items must be answered) 1 Diagnosis: 2 Recommended Treatment: 3 Prognosis: 4 The current level of capacity of the patient is: 5 In your opinion, is the patient capable of exercising the following? (Use checkboxes Below) Right to marry: Right to vote: Right to personally apply for government benefits: Right to have a driver's license: Right to travel: Right to seek or retain employment: Right to contract: Right to sue and be sued: Right to manage property or to make any give of disposition: Right to determine residence: Right to consent to medical treatment: Right to make decisions about social environment or social aspects: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No 6 Date of Examination: Doctor Signature Type/Print Doctor Name Doctor Address (Street Address, City, State, Zip) Date of Doctor's Signature American LegalNet, Inc. www.FormsWorkFlow.com