Petition for Appointment of Guardian

SURROGATE'S COURT OF THE STATE OF NEW YORK

COUNTY OF

Proceeding for the Appointment of a Permanent
Guardian of the Person and Estate of
An Adult

(Name of Respondent) Family File No.

TO THE FAMILY COURT:

AFFIDAVIT (CERTIFICATION) OF EXAMINING PHYSICIAN OR LICENSED PSYCHOLOGIST

File No.

Pursuant to SCPA Article 17-A

STATE OF NEW YORK )
COUNTY OF ) ss.:

I, (Name of Physician or Licensed Psychologist),

Physician Licensed Psychologist,
being duly sworn, deposes and says:

1. My license number is:

2. My offices are located at

(street address, city, county, state, zip code).

3. My professional knowledge and/or background in the care and treatment of persons with
mental retardation developmental disabilities is as follows:

4. I have examined the Respondent

on (dates). I have performed the following tests or evaluations
of the Respondent. (Set forth in detail the names of tests and/or evaluations, dates
performed and results.)

I have reviewed the following tests or evaluations performed on Respondent. (Set forth in
detail the names of tests and/or evaluations, dates performed, results and names of
doctors who performed the tests and/or evaluations.)

5. The mental and physical condition of the Respondent is as follows: (Describe in detail.)
(Include only the appropriate diagnosis)

6. Mentally Retarded. Based upon the foregoing, it is my conclusion the Respondent is
mentally retarded and in my opinion incapable of managing himself and/or his affairs by reason
of mental retardation. The nature and degree of the mental retardation is as follows: (Describe)

7. Developmentally Disabled. Based upon the foregoing, it is my conclusion that the
Respondent is developmentally disabled and in my opinion he has an impaired ability to
understand and appreciate the nature and consequences of decisions, which results in
Respondent being incapable of managing himself and/or his affairs by reason of developmental
disability, and whose disability is attributable to:

A. Cerebral palsy, which originated before the Respondent attained the age of
twenty-two. (Describe, in detail, the nature, degree and origin of the disability.)

B. Epilepsy, which originated before the Respondent attained the age of twenty-
two. (Describe, in detail, the nature, degree and origin of the disability).

C. Neurological impairment, which originated before the Respondent attained the
age of twenty-two. (Describe, in detail, the nature, degree and origin of the
disability.)

D. Autism, which originated before the Respondent attained the age of twenty-two.
(Describe, in detail, the nature, degree and origin of the disability.)

E. Traumatic head injury. (Describe, in detail, the nature, degree and origin of
the disability.)

F. A condition, which originated before the Respondent attained the age of twenty-
two, found to be closely related to mental retardation, because such condition results in
similar impairment of general intellectual functioning or adaptive behavior to that of
mentally retarded persons. (Describe, in detail, the nature, degree and origin of the
disability.)

G. Dyslexia resulting from a disability described in subdivision (a) through (f) or
mental retardation which condition originated before the Respondent attained the age of
twenty-two. (Describe in detail the nature, degree and origin of the disability or
mental retardation.)

8. The condition of the Respondent is permanent in nature or likely to continue indefinitely.
OR
The condition of the Respondent is not permanent in nature nor likely to continue
indefinitely.

9. There are no circumstances warranting Respondent's nonappearance at the hearing
required by the court. Respondent's presence at the hearing should be dispensed with
because he is medically incapable of being present to the extent that attendance is likely to
result in physical harm to the Respondent. (Explain in detail.)

OR

10. Respondent's presence at the hearing should be dispensed with for the following
reasons: (Set forth facts and circumstances which would result in the court finding that
the Respondent's presence at the hearing would not be in his/her best interest.)

OR

11. Based upon the foregoing, it is my conclusion that the Respondent is not capable of
understanding and appreciating the nature and consequences of health care decisions,
including the benefits and risks of and alternatives to any proposed health care, and of reaching
an informed decision in order to promote his own well being. A health care decision may include
a decision to withhold or withdraw life-sustaining treatment as defined in subdivision (e) of
Section 81.29 of the Mental Hygiene Law.

OR

12. Based upon the foregoing, it is my conclusion that the Respondent is capable of
understanding and appreciating the nature and consequences of health care decisions,
including the benefits and risks of and alternatives to any proposed health care, and of reaching
an informed decision in order to promote his own well being. A health care decision may
include a decision to withhold or withdraw life sustaining treatment as defined in subdivision (e)
of Section 81.29 of the Mental Hygiene Law.

OR

13. Based upon the foregoing, it is my conclusion that the Respondent has a
developmental disability, as defined in Section 1.03 of the Mental Hygiene Law, which includes
mental retardation, or results in a similar impairment of general intellectual functioning or
adaptive behavior so that such person is incapable of managing himself or herself, and/or his or
her affairs by reason of such developmental disability, and that the Respondent is not capable
of understanding and appreciating the nature and consequences of health care decisions,
including the benefits and risks of and alternatives to any proposed health care, and
of reaching an informed decision in order to promote his own well being. A health care decision
may include a decision to withhold or withdraw life-sustaining treatment as defined in
subdivision (e) of Section 81.29 of the Mental Hygiene Law. Based upon the foregoing, it is my
conclusion that the Respondent is capable of understanding and appreciating the nature and
consequences of health care decisions, including the benefits and risks of and alternatives to
any proposed health care, and of reaching an informed decision in order to promote his own
well being. A health care decision may include a decision to withhold or withdraw life sustaining
treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law.

Sworn to before me this day of , 20