Statement Of Expert Evaluation {17.1}

<document>PROBATE COURT OF BUTLER COUNTY, OHIOIN THE MATTER OF GUARDIANSHIP OF Case No.STATEMENT OF EXPERT EVALUATIONDefinition of Incompetent (R.C. 2111.01(D)): "Incompetent means any person who is so mentally impaired as a result of a physical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide for his family or other persons for whom he is charged by law to provide, or any person confined to a penal institution within this State." The Statement of Evaluation does not declare the prospective ward competent or incompetent, but is evidence to be considered by the Court. The fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant/Guardian.1. This Statement of Evaluation is for:Guardianship Application. (To be completed by a Licensed Physician or Licensed Clinical Psychologist, and attached to the Application).Guardian's Report. (Evaluation and Statement by a Licensed Physician, Licensed Clinical Psychologist, Licensed Social Worker, or Mental Retardation Team to be completed within three months of date of the report. R.C. 2111.49(A)(1)(i).) 2. Statement completed by: (please type or print)NameAddressPhoneWho is a:Licensed PhysicianLicensed Clinical PsychologistLicensed Social WorkerMental Retardation Team3. Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward.4. Is the prospective ward mentally impaired?NoYes9/1/91FORM 17.1 -STATEMENT OF EXPERT EVALUATION2001 © American LegalNet, Inc.5. A. Is there observed or reported evidence of mental impairment?YesNoDescribe:B. If reported, name source: 6. If the prospective ward is mentally impaired, what is the cause? 7. A. Is there observed or reported evidence of physical impairment?YesNoDescribe:B. If reported, name source: 8. Can the prospective ward conduct business affairs without the aid of a guardian?YesNoComments:9. Can the prospective ward properly care for himself without the aid of a guardian?YesNoComments:10.(TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianshipshould be: ContinuedTerminated.11.(TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) In my opinion, theapplication for guardianship: Should be granted.Should not be grantedADDITIONAL COMMENTSI certify that I have evaluated for the purpose of guardianship.Date of EvaluationEvaluator2001 © American LegalNet, Inc.</document>