Fill and Sign the Prior to Examination by Form

GN-3125, 10/06 Notice of Rights Prior to Examination by Physician/Psychologist §54.36, W isconsin Statutes This form shall not be modified. It may be suppleme nted with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Notice of Rights Prior to Examination by Physician or Psychologist Date of Birth Case No. For Official Use I am a physician/psychologist. I have been requeste d to examine you and submit a report of my professi onal opinion of your need for a guardian. The physician-patient privilege and psychologist-patient privilege relating to confidential communications does not apply. Prior to the examination on which my report will be based, you need to be informed that: 1. Statements that you make may be used as a basis for a finding of incompetency. 2. You have the right to refuse to participate in t he examination (in the absence of a court order req uiring your participation) or speak to me. 3. I am required to report to the court even if you do not speak to me. By providing you with notice of these rights, there is a presumption that you understand that you do n ot need to speak to me. After the examination has been completed, I will su bmit a written report to the court stating my opinion on the presence and likely duration of any medical or othe r condition that may be causing you to have incapac ity and on your need for a guardian. My report will also state my opinion of the extent that any incapacity affec ts your ability to exercise specific rights and the extent of any powe rs recommended to be transferred to a guardian. Proof of Informing Individual of Rights Prior to Ex amination I state that on (date) at (place) and prior to examination of the individual, I informed the individual of the above rights. Signature of Examiner Name Printed or Typed Name of Attorney Address Telephone Number Bar Number Address