Examining Physicians or Psychologists Report

Examining Physician’s or Psychologist’s Report

CONFIDENTIAL COURT FORM GN-3130, 05/16 Examining Physician’s or Psychologist’s Report §54.36, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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STATE OF WISCONSIN, CIRCUIT COURT, COUNTY

IN THE MATTER OF Amended

Examining Physician’s or Psychologist’s Report

Date of Birth: Case No.

PATIENT INFORMATION:

Date of Birth: Age: Gender: Female Male Marital Status:

If available: Height Weight Eyes Hair Color

Children:

Educational Background:

Veteran Status:

Occupation and Employment Status:

Brief History:

Prior to beginning your evaluation of this individual, did you read to him/her the “STATEMENT TO BE READ TO THE INDIVIDUAL PRIOR TO EXAMINATION?” Yes No

If no, Explain:

Did the individual appear to understand? Yes No

Comment:

EXAMINATION

Name of Examiner:

Date of Examination: Time spent with the individual:

Place of Examination:

Collateral sources used as part of your evaluation

Records:

Interviews:

Other:

1. Check this box only if ALL of the following are true: sudden and catastrophic injury/illness, unresponsive, likely to persist, not possible to interview/evaluate, alternate decision maker required.

2. Did the individual's presentation suggest sedation, intoxication, delirium or other condition affecting participation? Yes No

Explain:

3. A. Estimate the individual’s level of intelligence:

B. Describe the individual’s level of functional knowledge:

4. Note level of impairment and describe examination findings in the following areas:

Orientation Intact Mild Impairment Moderate Severe

Findings:

Attention/Concentration Intact Mild Impairment Moderate Severe

Findings:

Sensory/Motor Functioning Intact Mild Impairment Moderate Severe

Findings:

Language/Communication Intact Mild Impairment Moderate Severe

Findings:

Memory Intact Mild Impairment Moderate Severe

Findings:

Reasoning Intact Mild Impairment Moderate Severe

Findings:

Other Executive Functioning (Insight, Judgment, Planning, Initiation, etc.) Intact Mild Impairment Moderate Severe

Findings:

Emotional/Behavioral Functioning Intact Mild Impairment Moderate Severe

Findings:

5. Does the individual adequately understand and appreciate the nature and consequences of any impairment he/she may have? Yes No

Explain:

6. A. Does the individual have incapacity due to his/her impairments? Yes No

B. Is this incapacity permanent? Yes No

C. Using the definitions on the instruction sheet, specify the condition(s) related to the incapacity.

Developmental disability Is this condition likely to be permanent? Yes No

Serious and persistent mental illness Is this condition likely to be permanent? Yes No

Degenerative brain disorder Is this condition likely to be permanent? Yes No

Other like incapacities Is this condition likely to be permanent? Yes No

What are the diagnoses for each checkbox above?

Explain:

7. Does the individual’s incapacity interfere with ability to:

A. Receive and evaluate information? Yes No

B. Use information in a decision process? Yes No

C. Communicate decisions? Yes No

D. Protect him/herself from abuse, exploitation, neglect or rights violation? Yes No

E. Meet essential requirements of his/her health and safety? Yes No

F. Manage his/her property and financial affairs? Yes No

G. Address risk of property being dissipated in whole or in part? Yes No

H. Provide for his/her own support? Yes No

I. Prevent financial exploitation? Yes No

Explain how the individual's impairments result in the incapacities in A. – I. noted above:

8. Would any of the following less restrictive interventions eliminate need for guardianship for this individual?

Yes Training or education No

Yes Support services No

Yes Assistive devices No

Yes Advanced planning (e.g. Powers of attorney, trust, etc.) No

Yes Representative payee No

F. Other:

Explain why a less restrictive measure is or is not appropriate for this individual:

9. Does the individual have the evaluative capacity to:

A. Execute a will? Yes No

B. Serve on a jury? Yes No

C. Register to vote or vote in an election? Yes No

10. A. Does the individual have the evaluative capacity to:

(1) Consent to marriage? No Yes Yes, with guardian approval

(2) Apply for an operator’s/driver’s license? No Yes Yes, with guardian approval

(3) Apply for a hunting license? No Yes Yes, with guardian approval

(4) Apply for a fishing license? No Yes Yes, with guardian approval

(5) Apply for any other license? No Yes Yes, with guardian approval

(6) Consent to sterilization? No Yes Yes, with guardian approval

(7) Consent to organ, tissue, or bone marrow donation? No Yes Yes, with guardian approval

Comments:

10. B. Does the individual have the evaluative capacity to:

(1) Consent to medical examination and treatment, and consent to voluntary medication, including psychotropic medication that is in the individual’s best interests? No Yes, independently Yes, with the following limitations

(2) Authorize participation in an accredited or certified research project if minimal risk and might help the individual or others? No Yes, independently Yes, with the following limitations

(3) Authorize participation in research with greater than minimal risk if evidence indicates the individual would have elected to participate? No Yes, independently Yes, with the following limitations

(4) Consent to experimental treatment in the individual’s best interests? No Yes, independently Yes, with the following limitations

(5) Consent to receipt by individual of social and supported living services? No Yes, independently Yes, with the following limitations

(6) Consent to release of confidential records other than court, treatment, and individual health care records and re-disclosure as appropriate? No Yes, independently Yes, with the following limitations

(7) Make decisions related to mobility and travel? No Yes, independently Yes, with the following limitations

(8) Choose providers of medical, social, and supported living services? No Yes, independently Yes, with the following limitations

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(9) Make decisions regarding educational and vocational placement and support services or employment? No Yes, independently Yes, with the following limitations

(10) Make decisions regarding initiating a petition for termination of marriage? No Yes, independently Yes, with the following limitations

11. Is the individual prescribed psychotropic medications? Yes No

If Yes and the individual is refusing or resisting this course of treatment, do you recommend a full evaluation regarding capacity to refuse psychotropic medications? Yes No

Comments:

PROTECTIVE PLACEMENT(#12 - #14)

12. Does this individual require placement in a licensed, certified or registered setting? Yes No

A. If yes, does the individual have a primary need for residential care and custody? Yes No

B. If yes, does the individual's incapacity render him/her so incapable of providing for his/her own care or custody as to create a substantial risk of serious harm to himself/herself or others? Yes No

C. If yes, is the individual’s incapacity permanent or likely to be permanent? Yes No

Explain:

If you answered “NO” to any part of #12, skip to #14.

13. Do the placement needs of this individual include: (Check all that apply)

24 hour supervision?

A secure setting with monitored egress?

A locked setting?

On site skilled nursing care?

Explain:

14. In lieu of protective placement for this individual, would you recommend protective services? Yes No

Specify:

15. Do you believe this individual is able to attend court hearings?

A. Yes.

B. There are medical contraindications to his/her attendance at a hearing. The individual could participate if the hearing was held at the individual’s location.

C. There are other contraindications to the individual’s attendance at a hearing.

Explain:

16. If you have any additional comments you feel are important in evaluating the individual’s need for a guardianship and/or protective placement or services, make them here.

Comments:

See attached

TO THE COURT:

I am a physician. psychologist.

This report is made to the Court as part of a proceeding to appoint a guardian for an individual on the ground that the individual allegedly has incompetency. It contains my professional opinion regarding the presence and likely duration of any medical or other condition causing this individual to have incapacity.

I certify that I have, by personal examination and inquiry, satisfied myself as to the condition of capacity of this individual and the result of my evaluation and inquiry will be found in my answers to the above questions, which are true to the best of my knowledge and to a reasonable degree of professional certainty.

CONFIDENTIAL COURT FORM

GN-3130, 05/16 Examining Physician’s or Psychologist’s Report

This form shall not be modified. It may be supplemented with additional material.

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