GN-3130ExaminingPhysiciansorPsychologistsReport.doc

Examining Physician’s or Psychologist’s Report INSTRUCTIONS NOTE: This report will be used in a legal proceeding to determine if this individual is in need of a guardian or in need of protective placement or protective services. Prior to examining this individual, you must inform the individual of his/her rights. Those rights are contained in the statement below and should be read by you to the individual before you begin your examination. Please answer the questions to the best of your ability, to a reasonable degree of professional certainty. Any questions that you cannot answer should be marked “unknown.” Type or print your answers neatly. You may supplement this report with attachments. STATEMENT TO BE READ TO THE INDIVIDUAL PRIOR TO EXAMINATION I have been asked to give a professional opinion about your need for a guardian and for protective placement or protective services. Before we begin, I must tell you: Things you say to me may be used to decide if you need a guardian. You have the right to refuse to participate in this evaluation, unless a court ordered you to participate. You have the right to refuse to speak with me. I am required to report to the Court even if you do not speak to me. What we discuss is not confidential and may be shared in Court. Definitions Developmentally Disabled: A?disability attributable to intellectual disability, cerebral palsy, epilepsy, autism, or another neurological condition closely related to intellectual disability or requiring treatment similar to that required for individuals with intellectual disability, which has continued or can be expected to continue indefinitely, substantially impairs an individual from adequately providing for his or her own care or custody, and constitutes a substantial handicap to the afflicted individual. The term does not include dementia that is primarily caused by degenerative brain disorder. Serious and Persistent Mental Illness: A mental illness that is severe in de