Statement Of Expert Evaluation
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4PROBATE COURT OF WARREN COUNTY, OHIO
IN THE MATTER OF GUARDIANSHIP OF ___________________________________
__________________
CASE NO.
STATEMENT OF EXPERT EVALUATION
[Sup. R. 66 & R.C. 2111.49]
Definition of Incompetent (R.C. 2111.01(D)): “”Incompetent” means any person who is so mentally impaired as a result of
mental pr 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 that individual competent or incompetent, but is evidence to be considered
by the Court. The fee for completing this evaluation WILL NOT be paid by the Probate Court. Each evaluator should
secure payment from the Applicant/Guardian.
1.
This Statement of Expert Evaluation is to be filed with or attached to:
A.
Guardianship Application: Completed by
Licensed Physician or
Licensed Clinical
Psychologist prior to filling and attached to the application.
B.
Guardian’s Report: Completed by
Licensed Physician
Licensed Clinical Psychologist
Licensed Independent Social Worker
Licensed Professional Clinical Counselor or
Mental Retardation Team.
The evaluation or examination shall be completed within three months prior to the date of the
Report. R.C. 2111.49
C.
Application for Emergency Guardian:
of a person: a Licensed Physician shall complete
the Supplement for Emergency Guardian, form 17.1A with specificity indication the emergency,
and why immediate action is required to prevent significant injury to the person. The Supplement
shall be signed, dated, and attached as part of this completed Statement.
2.
Statement completed by:
Name & Title/Profession: __________________________________________________________________________
Business Address: _______________________________________________________________________________
Business Telephone Number: ______________________________________________________________________
3.
Date(s) of evaluation: _____________________________________________________________________________
Place(s) of evaluation: ____________________________________________________________________________
Amount of time spent on evaluation: _________________________________________________________________
Length of time the individual has been your patient: _____________________________________________________
17.1 STATEMENT OF EXPERT EVALUATION
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