Free Evaluation Report of Licensed Physician - West Virginia

EVALUATION REPORT OF LICENSED PHYSICIAN/PSYCHOLOGIST

INSTRUCTIONS FOR COMPLETION OF REPORT
A. This form is a required submission under West Virginia Code: § 44A-2-3 in a case seeking the court appointment of a guardian and/or conservator for an alleged "protected person" and must be completed by a licensed physician or psychologist. Since the law requires that this report address certain matters contained in the Petition seeking such appointment, it will be necessary for you to have a true copy of the completed Petition before you complete this form. Please insure that the Petitioner has provided you with a copy of the Petition intended to be filed. All information provided in this report must be printed or typed and be clearly readable. All information requested MUST be provided, if known. If unknown, you must state it is unknown. Please be sure you read and answer all questions carefully and in as much detail as possible. Answers to some questions may require more space than provided. If so, attach additional pages as needed and label each response on such page(s) with the number of the applicable question.

B. C. D. E.

I, _____________________________________________, a licensed [check category] __________ physician __________ psychologist, in the State of ____________________________, license number _____________________ hereby certify that I have examined and/or evaluated the condition of [insert name of alleged Protected Person here] __________________________________________________, and that the examination(s) or assessment(s) performed which form the basis of this report were conducted on the following date(s): ________________________________________________________ and hereby submit this report and evaluation with the following findings: 1. West Virginia Code: § 44A-1-4(c) defines a "protected person" as an adult individual, eighteen years of age or older, who has been found by a court, because of mental impairment, to be unable to: (a) receive and evaluate information effectively, OR (b) respond to people, events and environments to such an extent that the individual lacks the capacity to either: (i) meet the essential requirements for his or her health, care, safety, habitation, or therapeutic needs without the assistance or protection of a guardian, OR manage property or financial affairs or provide for his or her support or for the support of legal dependents without the assistance or protection of a conservator.

(ii)

.SCA-CG 902-1 / 6-94

Evaluation Report of Physician/Psychologist ­ Page 1 of 5 Pages

(CONTINUED FROM PAGE 1) 1. This same section also provides that even if the Court determines that the person displays poor judgment, this
finding alone is not sufficient evidence to determine that the person is a "protected person" as defined above. CONSIDERING THIS DEFINITION, IN MY OPINION, I FIND THE ALLEGED PROTECTED PERSON [initial appropriate finding]: __________ __________ IS NOT INCAPACITATED [If you have initialed this finding, go to Question 2] LACKS CAPACITY [If you have initialed this finding, complete Questions 1a and 1b below]

1a. DESCRIBE THE NATURE, TYPE AND EXTENT OF THE PERSON'S INCAPACITY: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

1b. THE PERSON'S SPECIFIC COGNITIVE AND FUNCTIONAL LIMITATIONS ARE: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

2. MY EVALUATION OF THE PERSON'S MENTAL AND PHYSICAL CONDITION IS AS FOLLOWS [Where
appropriate, include an evaluation of the Person's educational condition, adaptive behavior and social skills]:

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
SCA-CG 902-2 / 6-94 Evaluation Report of Physician/Psychologist ­ Page 2 of 5 Pages

2. (CONTINUED FROM PAGE 2) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. IF THE PETITION CONTAINS A REQUEST FOR A GUARDIAN, TEMPORARY GUARDIAN AND/OR,
LIMITED GUARDIAN, DESCRIBE THE SERVICES, IF ANY, CURRENTLY BEING PROVIDED FOR THE PERSON'S HEALTH, CARE, SAFETY, HABILITATION OR THERAPEUTIC NEEDS. INCLUDE A RECOMMENDATION AS TO THE MOST SUITABLE LIVING ARRANGEMENT AND, WHERE APPROPRIATE, THE MOST SUITABLE TREATMENT OR HABILITATION PLAN AND THE REASON'S FOR SUCH RECOMMENDATION(S):

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. IT IS MY OPINION THAT THE APPOINTMENT OF [initial appropriate office]
__________ A GUARDIAN __________ A CONSERVATOR __________ A GUARDIAN AND A CONSERVATOR IS NECESSARY FOR THIS PERSON.

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Evaluation Report of Physician/Psychologist ­ Page 3 of 5 Pages

5.

THE TYPE AND SCOPE OF GUARDIANSHIP AND/OR CONSERVATORSHIP NEEDED, AND THE REASONS THEREFOR, ARE AS FOLLOWS: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

6.

IF THE PETITION STATES THAT THE PERSON'S INCAPACITY WILL PREVENT THE PERSON'S ATTENDANCE AT THE HEARING [SEE: Petition for Appointment of Conservator/Guardian, Page 4, Question 16], IT IS MY OPINION THAT SUCH ATTENDANCE AT THE HEARING [initial appropriate finding]: __________ WOULD BE DETRIMENTAL TO THE PERSON'S HEALTH, CARE AND/OR SAFETY. __________ WOULD NOT BE DETRIMENTAL TO THE PERSON'S HEALTH, CARE AND/OR SAFETY.

[IMPORTANT NOTE: If a protected person is unable to appear at the hearing, the law requires that one of the following be submitted to the Court at the beginning of the hearing: (1) a physician's affidavit (Form 902A), (2) qualified expert testimony, or (3) evidence that the person refuses to appear. SEE: West Virginia Code: § 44A-2-9(c). This Evaluation Report is NOT the required physician's affidavit. The affidavit is a separate form which may only be completed by a physician.] 7.
IF IT APPEARS THE PERSON WILL ATTEND THE HEARING, IS THE PERSON ON ANY MEDICATION(S) THAT MAY AFFECT THE PERSON'S ACTIONS, DEMEANOR, AND PARTICIPATION AT THE HEARING? _______ YES ______NO [If "YES," describe the medication and the affect(s) such medication(s) may have] ______________________________________________________________________________ ______________________________________________________________________________ I, the undersigned evaluating physician/psychologist named on page 1 of this Report, do hereby certify that the foregoing report is complete and accurate to the best of my information and belief. I further certify that other individuals [initial appropriate category] __________did __________ did not perform, supervise or

review the assessment(s) or examination(s) upon which this Report is based, or otherwise made substantial contributions toward this Report's preparation. [If you initialed "DID," see note below and secure signatures of all such individuals on page 5.] Given under my hand this _______ day of _______________________, 20 ________.

____________________________________________________ EVALUATING PHYSICIAN/PSYCHOLOGIST
SCA-CG 902-4 / 6-94 Evaluation Report of Physician/Psychologist ­ Page 4 of 5 Pages

[West Virginia Code: § 44A-2-3(7) also requires the signatures of ". . . any other individuals who performed, supervised or reviewed the assessments or examinations upon which the report is based. . . ." or of any other person who made substantial contributions towards the report's preparation.]

We, the undersigned individuals, hereby certify that each individual signatory executing this Report below performed, supervised and/or reviewed the assessment(s) and/or examination(s) upon which the foregoing report is based, or made a substantial contribution toward the preparation of this Report, and that by signing below, each individual further certifies that to the best of his or her information and belief, the information contained in the foregoing report is complete and accurate. ___________ DATE ___________ DATE ___________ DATE ___________ DATE ___________ DATE ___________ DATE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE ________________________________ _______________________________________ SIGNATURE PRINT NAME AND TITLE

SCA-CG 902-5 / 6-94 Evaluation Report of Physician/Psychologist ­ Page 5 of 5 Pages