Fill and Sign the 1 I Am a Licensed Physician Mental Health Professional My Form

1. I am a licensedphysician. mental health professional. My speciality is 2. I last examined the individual on 3. Based on that examination and her/his medical record, the individual suffers from the following physical or psychological inf irmities: 4. These infirmities interfere in the following ways with the individual's ability to receive or evaluate information in making decisions: 5. The following is a list of all medications the individual is receiving, the dosage of each medication, and a description of the effects of each medication upon the individual's behavior: 6. I believe the individual, due to these described conditions, is not presently able to make informed decisions in the following areas: check all that apply determining where to live. handling personal financial affairs. consenting to supportive services. authorizing or refusing medical treatment. 7. The prognosis for improvement in the individual's conditions is . My recommendation for the most appropriate rehabilitation plan is attached. 8. Further comments are attached on a separate sheet. In the matter of Do not write below this line - For court use only JIS CODE: ROP/ROM Approved, SCAO FILE NO. PC 630 (9/11) REPORT OF PHYSICIAN OR MENTAL HEALTH PROFESSIONAL MCL 700.5304, MCR 5.405 REPORT OF PHYSICIAN OR MENTAL HEALTH PROFESSIONAL , alleged incapacitated individual if any Signature Date Address Name (type or print) City, state, zipTelephone no. STATE OF MICHIGAN PROBATE COURTCOUNTY OF USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.