Free 765 - Kentucky

AOC-765 Rev. 8-07 Page 1 of 3

Doc. Code: RIET

Case No._____________________ Court________________________

Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 387.540

REPORT OF INTERDISCIPLINARY EVALUATION TEAM

County_______________________

COMMONWEALTH OF KENTUCKY PETITIONER VS.

_____________________________________________ RESPONDENT

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We, the undersigned, hereby report to the court as follows: 1. That the nature and extent of the Respondent's disabilities may be described as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 2. That the evaluations ordered regarding the Respondent are current and were performed and signed by the following individuals:

Name Title Date Performed Evaluation________________________________________________________________________________________ Intellectual:_______________________________________________________________________________________
Name of individual that performed intellectual evaluation

Physical:_________________________________________________________________________________________ Educational:______________________________________________________________________________________ Adaptive Behavior:________________________________________________________________________________ Social Skills:______________________________________________________________________________________

AOC-765 Rev. 8-07 Page 2 of 3 3.

Doc. Code: RIET

That guardianship:



Is needed for the following reason: ________________________________________________________________________________________ ________________________________________________________________________________________



Is not needed for the following reason: ________________________________________________________________________________________ ________________________________________________________________________________________

4.

That the recommendation(s) of the type, scope, and duration of guardianship for the Respondent is/are as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________

5.

That conservatorship:



Is needed for the following reason: ________________________________________________________________________________________ ________________________________________________________________________________________



Is not needed for the following reason: ________________________________________________________________________________________ ________________________________________________________________________________________

6.

That the recommendation(s) of the type, scope, and duration of conservatorship for the Respondent is/are as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________

7.

That the social, educational, medical, and rehabilitative services currently being provided to the Respondent are as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

8.

That appropriate alternatives to guardianship/conservatorship:



Are available (explain): ________________________________________________________________________________________ ________________________________________________________________________________________



Are not available (explain): ________________________________________________________________________________________ ________________________________________________________________________________________

9.

That the recommendations and reasons as to the most appropriate treatment or rehabilitation plan and living arrangement for the Respondent are as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

AOC-765 Rev. 8-07 Page 3 of 3 10.

Doc. Code: RIET

That for the Respondent to attend the hearing on the Petition filed herein:


11.

Would subject him/her to serious risk of harm. Would not subject him/her to serious risk of harm.

That appended hereto is a list of all medications currently being given the Respondent on a continuous basis, the dosage of the medication, and a description of its impact upon the Respondent's mental and physical condition and behavior. That any dissenting opinions or other comments are as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

12.

_________________________________________ Date

_____________________________________________ Signature of Licensed Physician

_____________________________________________ Signature of Licensed/Certified Psychologist

_____________________________________________ Signature of Licensed/Certified Social Worker

_____________________________________________ Signature of Other

_____________________________________________ Name of Facility or Agency _____________________________________________ _____________________________________________ Address _____________________________________________ Telephone Number

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