Statement Of Expert Evaluation - Probate Court Of Clark County, Ohio
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PROBATE COURT OF CLARK COUNTY, OHIO
Richard P. Carey, Judge
In the Matter of the GUARDIANSHIP of:_______________________________________________________
Case No._______________________
Date:________________________
STATEMENT OF EXPERT EVALUATION
Definition of Incompetent (R.C. 2111.01(D)): "Incompetent means any person who is so mentally impaired
as a result of a physical or mental illness or disability, or retardation, or as a result of chronic
substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide
for his family or other persons for whom he is charged by law to provide, or any person confined to a
penal 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/Guardian.
This Statement of Evaluation is for:
1.
_____
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
three months of date of the report. R.C.2111.49(A)(1)(i).)
2.
Statement completed by: (please type or print)
Name:
______________________________________________________________________
Address:
______________________________________________________________________
Phone:
______________________________________________________________________
Who is a:
_____
Licensed Physician
_____
Licensed Clinical Psychologist
_____
Licensed Social Worker
_____
Mental Retardation Team
3.
Date(s) of Evaluation: _______________________________________________________________
Place(s) of evaluation: _______________________________________________________________
Time spent with subject: _____________________________________________________________
Length of time subject has been your patient: ___________________________________________
4.
Is the subject presently under medication: ______yes ______no
If yes, what is the medication, dosage, and purpose.
______________________________________________________________________________________
______________________________________________________________________________________
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