PROBATE COURT OF GREENE COUNTY, OHIO
THOMAS M. O’DIAM, JUDGE
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
a mental or 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 the 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
the filing 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 the person: a Licensed Physician shall complete the Supplement
for Emergency Guardian, form 17.1A with specificity indicating 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:
FORM 17.1 - STATEMENT OF EXPERT EVALUATION
5/9/06