Fill - Free fillable IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA (West Virginia Supreme Court of Appeals) PDF form

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.

B. All information provided in this report must be printed or typed and be clearly readable.

C. All information requested MUST be provided, if known. If unknown, you must state it is unknown.

D. Please be sure you read and answer all questions carefully and in as much detail as possible.

E. 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.

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(13) 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

(ii) 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

.

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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]:

______________________________________________________________________________

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3. IS THE PERSON UNABLE TO HANDLE HIS OR HER OWN AFFAIRS DUE TO MENTAL ILLNESS OR

INSANITY? [initial appropriate response] __________YES ____________NO

If "Yes", what is the mental illness or insanity diagnosis?

______________________________________________________________________________________

If the person is unable to handle his or her own affairs due to mental illness or insanity, please provide the

following:

3a.

The gender of the Respondent is [initial one] ________male or ________ female.

3b. The race of the Respondent is believed to be [initial one] _________ White, _________ Black or

African American, __________ Hispanic or Latino, ________ Asian, ________ American Indian or

Alaska Native, or _________ Native Hawaiian or Other Pacific Islander, or _________ unknown.

3c. The height of the Respondent is _________ feet, and _________ inches.

3d.

The natural eye color of the Respondent is _____brown, ______blue, ______ green, ______hazel, or

_____ other.

4. 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):

______________________________________________________________________________

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5.

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.

6. THE TYPE AND SCOPE OF GUARDIANSHIP AND/OR CONSERVATORSHIP NEEDED, AND THE

REASONS THEREFOR, ARE AS FOLLOWS

:

______________________________________________________________________________________

7. IF THE PETITION STATES THAT THE PERSON'S INCAPACITY WILL PREVENT THE PERSON'S

ATTENDANCE AT THE HEARING [

SEE: Petition for Appointment of Guardian/Conservator, 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 (GC Form 5), (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.]

8. 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]

_______________________________________________________________________________________

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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 _______________________ [month], ________ [year].

____________________________________________________

EVALUATING PHYSICIAN/PSYCHOLOGIST

[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.

___________ ________________________________ _______________________________________