Statement Of Expert Evaluation - Probate Court Of Clark County, Ohio (Page 3 of 3) in pdf

11 .

Could you determine the subject's general level of intelligence and fund of knowledge? Yes _____ No ______

If yes, explain:___________________________________________________________________________________

___________________________________________________________ _____________________________

12 .

Do you believe this subject in his/her present condition, is substantially capable of managing his/her finances

and property?

Yes ______

No _______

If yes, explain: ___________________________________________________________________________________

___________________________________________________________ _____________________________

13 .

Do you believe this subject in his/her present condition, is substantially capable of caring or his/her activities of

daily living or making decisions concerning medical treatments, living arrangements, and diet? Yes ____ No____

If yes, explain: ______________________________________________________________________________________

___________________________________________________________ _______________________________

14 .

Prognosis:________________________________________________________________________________________

15 .

(TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be:

Continued _____ Terminated _____.

16 .

(TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) In my opinion, the

application for guardianship:

Should be granted ______ Should not be granted ______.

ADDITIONAL COMMENTS

_____________________________________________________________________________________________________

I certify that I have evaluated the subject on _________________ _______________20___ for the purpose of guardianship.

Date _______________________________________ 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

Statement Of Expert Evaluation - Probate Court Of Clark County, Ohio Page 3