Fillable INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT (Unified Judicial System of Pennsylvania)

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INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT (Unified Judicial System of Pennsylvania)

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Form G-06 Effective June 1, 2019
INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT
To establish incapacity, the petitioner must present testimony from an individual
qualified by training and experience in evaluating persons with incapacities of the type alleged
by the petitioner. As an accommodation to such expert witnesses, the court may accept a
complete and legible expert report in accordance with the attached form in lieu of expert
testimony, whether in person or by deposition, unless otherwise required by rule or order of court.
Form G-06 Effective June 1, 2019
COURT OF COMMON PLEAS OF
________________________ COUNTY PENNSYLVANIA
ORPHANS’ COURT DIVISION
EXPERT REPORT
RE: _______________________________________________________________________
An Alleged Incapacitated Person (AIP)
No. ____________________
PART I: PROFESSIONAL BACKGROUND (You may attach your curriculum vitae, if it provides an-
swers to Questions 1 through 5. Please answer those questions not covered by curriculum vitae.)
1. Name: _______________________________________ Title: _______________________________
2. Professional Address: ___________________________________________________________________
3. Complete education information:
4. Do you have any active professional licenses? Yes No
If yes, indicate in what state or states you are licensed as well as the date(s) issued.
______________________________________________________________________________________
______________________________________________________________________________________
List any board certifications: ______________________________________________________________
5. An Incapacitated Person is legally defined as: An adult whose ability to receive and evaluate information
effectively and communicate decisions in any way is impaired to such a significant extent that he/she is
partially or totally unable to manage his/her financial resources or to meet
essential requirements for his/
her physical health and safety.
Do you have experience evaluating whether or not an individual is incapacitated? Yes No
If yes, indicate the basis of your experience:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name of Institution Type of Degree Received Date Completed
Undergraduate
Graduate
Post-Graduate
p. 1 of 5
Form G-06 Effective June 1, 2019
PART II: ALLEGED INCAPACITATED PERSON (AIP)
6. a. Have you treated, assessed, or evaluated the AIP?
Yes No
b. Indicate the date(s) and location of any treatment, assessment, or evaluation you have provided or made
over the last two (2) years:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
c. If 6a. is yes, what tests have you or others administered, e.g., mini mental status exam (MMSE),
Montreal Cognitive Assessment (MOCA), St. Louis University Mental Status Exam (SLUMS), etc.?
List dates administered and the score. (Attach test results, not just the score.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. What is the present condition of the AIP? List all known medical and psychiatric diagnoses and current
symptoms. (You may attach a list from your records.)
Diagnosis Symptoms/Manifestations
8. List all known medications, including over-the-counter, that the AIP is taking. For each known medication,
indicate, if known, the prescribing physician and the diagnosis for which the medication was prescribed or
the reason for taking. (You may attach a list from your records.)
Medication Diagnosis/Reason Taken Prescribing Physician
p. 2 of 5
Form G-06 Effective June 1, 2019
9. Indicate the AIP’s ability to perform the following functions:
Unimpaired
Needs Some
Help
(Explain in #10 )
Totally
Impaired
Not Assessed
or Not Enough
Information
Receiving and evaluating information
effectively
Communicating decisions
Ability to give informed consent
Short-term memory
Long-term memory
Activities of daily living
Managing finances (including paying bills,
making deposits, withdrawals and working
with financial institutions)
Managing health care (including following
doctor’s orders and managing/taking
medications)
Responding to emergency situations
Ability to resist scams
Providing for physical safety
10. For any response in Question 9 where the AIP “needs some help,” please describe the type and extent of
assistance needed.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
11. What recommendations have you made or would you make concerning services necessary to meet the
essential requirements for the AIP’s physical health and safety?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
p. 3 of 5
Form G-06 Effective June 1, 2019
12. What recommendations have you made or would you make concerning management of the AIP’s
finances?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
13. As indicated in Question 5, an Incapacitated Person is legally defined as: An adult whose ability to
receive and evaluate information effectively and communicate decisions in any way is impaired to such a
significant extent that he/she is partially or totally unable to manage his/her financial resources or to meet
essential requirements for his/her physical health and safety.
In your expert opinion, within a reasonable degree of professional certainty and based on your knowledge,
skills, experience, and education, is the AIP incapacitated?
Yes, totally impaired Yes, partially impaired No
14. In your opinion, the most appropriate, least restrictive living situation for the AIP is (check one):
The AIP can be left alone without supervision
Home ( with part-time home health aide or 24/7 assistance)
Independent living facility (room and board provided, emergency services readily available)
Assisted living facility (room and board provided, assistance with some activities of daily
living)
Secure facility (Alzheimer’s/Mental Health for safety and basic needs)
Skilled nursing facility
15. If your responses in Question 9 indicated that the AIP is totally impaired or “needs some help”, do you
expect the AIP’s abilities in the next 6 months to (Check best estimate):
Stay the same Improve Decline
Please explain:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART III: GUARDIANSHIP AND SERVICES
16. Are you aware of any circumstances, medical or otherwise, that create a need for the appointment of an
emergency guardian for the AIP?
Yes No
If yes, indicate reasons:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
p. 4 of 5
Form G-06 Effective June 1, 2019
18. Please provide any additional information that could assist the court in determining incapacity.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that
this verification is subject to the penalties of 18 Pa.C.S. § 4904 relative to unsworn falsification to authorities.
______________________________ __________________________________________________
Date Signature
__________________________________________________
Name (type or print)
__________________________________________________
Address
__________________________________________________
City, State, Zip
__________________________________________________
Telephone
__________________________________________________
Email
17. The AIP is required to be at the hearing, absent circumstances that could cause harm to the AIP. Putting
aside whether the court proceeding may be moderately upsetting to, confusing to or not understood by the
AIP, do you believe that the AIP’s presence at the hearing would cause harm to the AIP’s physical or
mental condition?
Yes No
Indicate reason for response:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
p. 5 of 5
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INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT (Unified Judicial System of Pennsylvania)

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Completed 6 December 2021

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