Report Of Physician {CCP 0211}

CCP N211 A (Rev. 08/16/16) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, PROBATE DIVISION File No. Estate of Alleged Person with a Disability REPORT OF PHYSICIAN , a licensed physician, submits the following Report on , an alleged person with a disability (the "Respondent"), based . [printed name of the physician] [printed name of the alleged person with a disability] upon evaluations of the Respondent performed on NOTE: The evaluations upon which this Report is based must have been performed within three (3) months of the date the Petition for guardianship is filed. 1. The following is a description of the nature and type of the Respondent's disability and an assessment of how the disability impacts on the ability of the Respondent to make decisions or to function independently, including an underlying diagnosis and a description of the manifestations of the disability: 2. The following is an analysis and the results of evaluations of the Respondent's mental and physical condition, and (if appropriate) a description of the Respondent's educational condition, adaptive behavior and social skills: 3. The following is my opinion as to whether guardianship is needed, the type and scope of the guardianship needed, and the reasons for my opinion, including whether the Respondent is totally or only partially incapable of making personal and financial decisions and if only partially, the kinds of decisions which the Respondent can and cannot make: 4. The following is my recommendation as to the most suitable living arrangement for the Respondent and (if appropriate) the treatment or habilitation plan for the Respondent, and the reasons for my recommendation: Next Page DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2 CCP N211 B (Rev. 08/16/16) File No. If the description of the Respondent's mental, physical and educational condition, adaptive behavior or social skills is based upon evaluations by other professionals, all professionals preparing evaluations must also sign this Report. 5. The following are the names, addresses, certifications, licenses or other credentials, and signatures of each other person who performed an evaluation upon which this Report is based: a. Name ______________________________________________________________________________________ Address ____________________________________________________________________________________ License (state and number)_____________________________________________________________________ Certification ________________________________________________________________________________ Other credentials _____________________________________________________________________________ Signature ___________________________________________________________________________________ b. Name ______________________________________________________________________________________ Address ____________________________________________________________________________________ License (state and number)_____________________________________________________________________ Certification ________________________________________________________________________________ Other credentials _____________________________________________________________________________ Signature ___________________________________________________________________________________ * [signature of the physician preparing this Report] [license (state and number)] [address of the physician] [city/state/zip] [physician's telephone] Certification ________________________________________________________________________________ Other credentials _____________________________________________________________________________ *This Report must be signed by a licensed physician. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 2