Psychologist Report

Examining Physician’s or Psychologist’s Report

STATE OF WISCONSIN, CIRCUIT COURT, COUNTY

IN THE MATTER OF

Date of Birth

Case No. Amended

Examining Physician’s or Psychologist’s Report

INSTRUCTIONS

NOTE: This report will be used in a legal proceeding to determine if this individual is in need of a guardian or in need of protective placement or protective services. Prior to examining this individual, you must inform the individual of his/her rights.

Please answer the questions to the best of your ability, to a reasonable degree of professional certainty. Any questions that you cannot answer should be marked “unknown.” Type or print your answers neatly.

STATEMENT TO BE READ TO THE INDIVIDUAL PRIOR TO EXAMINATION

I have been asked to give a professional opinion about your need for a guardian and for protective placement or protective services.

Before we begin, I must tell you:

• Things you say to me may be used to decide if you need a guardian.

• You have the right to refuse to participate in this evaluation, unless a court ordered you to participate.

• You have the right to refuse to speak with me.

• I am required to report to the Court even if you do not speak to me.

• What we discuss is not confidential and may be shared in Court.

DEFINITIONS

Developmentally Disabled: A disability attributable to intellectual disability, cerebral palsy, epilepsy, autism, or another neurological condition closely related to intellectual disability...

Serious and Persistent Mental Illness: A mental illness that is severe in degree and persistent in duration...

Degenerative Brain Disorder: The loss or dysfunction of an individual’s brain cells...

Other Like Incapacities: Those conditions incurred at any age that are the result of accident, organic brain damage...

Incapacity: Inability to effectively receive and evaluate information or to make or communicate a decision...

Impairment: Developmental disability, serious and persistent mental illness, degenerative brain disorder, or other like incapacities.

Meet the Essential Requirements for Physical Health or Safety: Perform those actions necessary to provide the health care, food, shelter, clothes, personal hygiene...

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Name of Examiner:

Date of Examination: Time spent with individual:

Place of Examination:

Date of Birth: Age: Gender: Female Male

Marital Status:

Children:

Educational Background:

Veteran Status:

Occupation and Employment Status:

Collateral sources used as part of your evaluation

Records:

Interviews with others:

Other:

Brief History:

EXAMINATION

1. A. 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:

B. Did the individual appear to understand? Yes No

Comment:

2. Check this box only if all listed conditions are true.

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

Explain:

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

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

5. 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 and 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 Intact Mild Impairment Moderate Severe

Findings:

Emotional and Behavioral Functioning Intact Mild Impairment Moderate Severe

Findings:

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

Explain:

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

B. Is this incapacity permanent? Yes No

C. Condition(s) related to incapacity:

Developmental disability Permanent? Yes No

Serious and persistent mental illness Permanent? Yes No

Degenerative brain disorder Permanent? Yes No

Other like incapacities Permanent? Yes No

Diagnoses:

8. Does the individual’s incapacity interfere with ability to receive and evaluate information? Yes No

Use information in a decision process? Yes No

Communicate decisions? Yes No

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

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

Manage his/her property and financial affairs? Yes No

Address risk of property being dissipated? Yes No

Provide for his/her own support? Yes No

Prevent financial exploitation? Yes No

Explain:

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9. Would any of the following less restrictive interventions eliminate need for guardianship?

A. Training or education Yes No

B. Support services Yes No

C. Assistive devices Yes No

D. Advanced planning Yes No

E. Representative payee Yes No

F. Other:

Explain:

10. Does the individual have the evaluative capacity to execute a will? Yes No

Serve on a jury? Yes No

Register to vote or vote in an election? Yes No

11. Does the individual have the evaluative capacity to independently:

A. Consent to marriage? Yes No only with guardian approval

B. Possess or apply for a motor vehicle license? Yes No only with guardian approval

C. Possess or apply for a hunting license? Yes No only with guardian approval

D. Possess or apply for a fishing license? Yes No only with guardian approval

E. Possess or apply for any other license? Yes No only with guardian approval

F. Consent to sterilization? Yes No only with guardian approval

G. Consent to organ, tissue, or bone marrow donation? Yes No only with guardian approval

Comments:

12. Does the individual have the evaluative capacity to:

A. Consent to medical examination and treatment... No Yes, independently

B. Accredited or certified research project... No Yes, independently

C. Research that might not help the individual... No Yes, independently

D. Consent to experimental treatment... No Yes, independently

E. Consent to receipt of social and supported living services... No Yes, independently

F. Consent to release of confidential records... No Yes, independently

G. Make decisions related to mobility and travel... No Yes, independently

H. Choose providers of medical, social, and supported living services... No Yes, independently

I. Make decisions regarding educational and vocational placement... No Yes, independently

J. Make decisions regarding initiating a petition for termination of marriage... No Yes, independently

13. Is the individual prescribed psychotropic medications? Yes No

If Yes and refusing or resisting, do you recommend a full evaluation regarding capacity to refuse psychotropic medications? Yes No

Comments:

PROTECTIVE PLACEMENT (#14 - #16)

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

A. If yes, primary need for residential care and custody? Yes No

B. If yes, incapacity create substantial risk of serious harm? Yes No

C. If yes, incapacity permanent or likely permanent? Yes No

Explain:

15. Placement needs include (check all that apply):

24 hour supervision

A secure setting with monitored egress

A locked setting

On site skilled nursing care

Explain:

16. In lieu of protective placement, would you recommend protective services? Yes No

Specify:

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

A. Yes.

B. Medical contraindications; could participate if held at individual’s location.

C. Other contraindications to attendance.

Explain:

18. Additional 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.

I certify that I have, by personal examination and inquiry, satisfied myself as to the condition of capacity of this individual...