Fill and Sign the Juvenile Dependency Superior Court Maricopa County Form

Name: _______________________________________________ Address: _____________________________________________ City/State/Zip: ________________________________________ Telephone: ___________________________________________ State Bar Code: _______________________________________ Client: _______________________________________________ IN THE SUPERIOR COURT OF THE ST ATE OF ARIZONA In and for the County of ________________________ _____________________________________________ IN RE: THE MATTER OF [ ] GUARDIANSHIP OF AND [ ] CONSERVATOR FOR: CASE NO. GUIDELINES FOR PHYSICIAN REPORT An Adult Incapacitated and Protected Person ___________________________________________________________________________________G&C7A Petitioner: fill in the information below and give this document to the Court -Appointed Physician immediately after the Ord er Appointing Physician is signed. Be sure a written report from the physician is given to everyone listed in the Order Appointing Physician no later than 10 ( ten ) days before the scheduled Hearing. Name of the adult person: ___________________________ ____________________________________________. Drivers License No. : ___________________________________________________________________________. Name of Petitioner: ____________________________________________________________________________. Petitioner's Address : ___________________________________________________________________________. Petitioner's Phone No.: __________________________________________________________________________. Date and Time of Court Hearing: _________________________________________________________________. Instructions to Court -Appointed Physician: A Court case has been filed that asks the Court to appoint a [ ] Guardian of and [ ] Conservator for the above -named adult incapacitated and protected person. Before the Court grants such Petition, the Court must decide if a mental, physical, or other cause exists which necessitates a guardianship and/or conservatorship. Therefore, the Court needs to know what yo u as a physician for the person think about the person's health. The Court's goal is to do all that is possible to help the person about whom this case is pending to live as fully as his/her mental or physical impairments allow. The Court realizes that y our time is valuable, and has developed the following questions to help you to prepare your report. If you want to use a different format to submit your report, please feel free to do that also, so long as you try to provide the same information that the Court requires. After you complete the report, give the original report to the Petitioner and he/she will see to it that the necessary copies are properly distributed. Please do not file your report with the Clerk of the Court. PLEASE date and sign your report. Thank you for your assistance. Questions for the Physician to Answer: 1. What is the date you last saw your patient? ________________________________________________________ 2. How long have you been his/her physician? ___________________ _____________________________________ 3. Why were you asked to do this evaluation? : [ ] You have been the person's physician for many years; [ ] You were asked to do so by this person's family; [ ] An Attorney selected you; [ ] Your office is cl ose to this person's residence; [ ] You are the doctor for this person's nursing home; [ ] Other ( please explain ): ________________________________________________________________ ______________________________________________________________________ ____________________ ___ __________________________________________________________________________________________ __. 4. What is your area of specialty?: _________________________________________________________________ 5. Are you Board Certified in this area?: ____________________________________________________________ 6. Are you Board Certified in any other areas?: ______________________________________________________ 7. Does this person appear to be having difficulty in any of the following areas?: [ ] Mental disorder; [ ] Physical illness; [ ] Chronic intoxication or drug use; [ ] Cognitive abilities; [ ] Any other areas: ______________________________________________________________________ __________________________________________________________________________________________ __. 8. If the person is having difficulty, please specify the nature of the illness, disorder, etc.: 9. Has this person been treated or hospitalized before this d ifficulty? If yes, when and where?: 10. Is the extent of the difficulty the person is experiencing limiting the following abilities?: [ ] To pay his/her bills; [ ] To obtain food; [ ] To provide adequate housing; [ ] To perform daily self -help skills; [ ] To live alone; [ ] To take medication appropriately; [ ] To make appropriate judgments that will protect him/her personally, physically, or financially. 11. If the person is currently on medication, please list them: 12. Do you belie ve that the medication is affecting the person's ability to respond coherently? 13. Do you believe that the medication is affecting the person's ability to ambulate? 14. Do you believe that a temporary halt on the medication would help you to better evaluate the person's condition? 15. Do you believe that a change in the dosage or type of medication would noticeably affect his/her mental or physical abilities? 16. Do you believe that any other type of mental or physical treatment would benefit this person's condition? If so, what? 17. Do you believe that this person would benefit from other types of therapy such as counseling? If so, what? 18. In your opinio n where should this person be living now? [ ] At home with a companion; [ ] At home with a nurse; [ ] In group care; [ ] In a boarding home; [ ] In a supervised care facility; [ ] In a nursing home; [ ] In a hospital; [ ] Other ( explain ): ______________________________________________________________________ __________________________________________________________________________________________ __. 19. Do you believe that this person's condition will improve in the next 6 ( six ) months to a year? 20. Do you feel that there is any reason for this Court to review this matter in the next 6 ( six ) months to a year? 21. Please make any additional comments or suggestions you think would help the Court in making this decision: Dated: _________________________________ ______________________________________ Signature of Physician