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.
__________________________________________, 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
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
(i) meet the essential requirements for his or her health, care, safety, habitation, or therapeutic needs
without the assistance or protection of a guardian
(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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