Form 17.1 - Statement Of Expert Evaluation - Probate Court Of Greene County, Ohio Page 3

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CASE NO.
☐ Yes
☐ No
8.
Is the individual physically impaired?
If yes: Description:
9.
Are there any special characteristics of the individual which should be considered in evaluating the individual for
☐ Yes
☐ No
guardianship:
If yes: Explain:
☐ Yes
☐ No
10.
Are there any indication of abuse, neglect or exploitation of the individual?
If yes: Explain
Do you believe the individual is capable of caring for the individual’s activities of daily living or making decisions
11.
☐ Yes
☐ No
concerning medical treatments, living arrangements and diet?
If no: Explain
Do you believe this individual is capable of managing the individual’s finances and property?
12.
☐ Yes
☐ No
If no: Explain
13.
Prognosis:
☐ Yes
☐ No
A. Is the condition stabilized?
☐ Yes
☐ No
B. Is the condition reversible?
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
FORM 17.1 - STATEMENT OF EXPERT EVALUATION
PAGE 3
5/9/06

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