Application For Appointment Of Guardian Of Alleged Packet Page 7
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17CASE NO._______________________
8.
Is the individual physically impaired?
Yes
No
If yes: Description
___________________________________________________________________________________________
9.
Are there any special characteristics of the individual which should be considered in evaluating the individual for
guardianship:
Yes
No
If yes: Explain
___________________________________________________________________________________________
___________________________________________________________________________________________
10.
Are there any indication of abuse, neglect or exploitation of the individual?
Yes
No
If yes: Explain ______________________________________________________________________________
___________________________________________________________________________________________
11.
Do you believe the individual is capable of caring for the individual’s activities of daily living or making
decisions concerning medical treatments, living arrangements and diet?
Yes
No
If no: Explain _______________________________________________________________________________
12
Do you believe this individual is capable of managing the individual’s finances and property?
Yes
No
If no: Explain
___________________________________________________________________________________________
13.
Prognosis:
A.
Is the condition stabilized?
Yes
No
B.
Is the condition reversible:
Yes
No
14.
In my opinion a guardianship should be:
Established/Continued
Denied/Terminated
I certify that I have evaluated the individual on _____________________________________, 20 __________.
Date:
_____________________________________
_____________________________________________
Signature of Evaluator
GUARDIAN’S REPORT ADDENDUM
(Not to be used with initial Application)
It is my opinion, based upon a reasonable degree of medical or psychological certainty, that the mental capacity of
this ward will not improve.
Date _______________________________________
_____________________________________________
Signature – Licensed Physician/Clinical Psychologist
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