Medical examination for Guardianship form
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REPORT OF EXAMINATION AND EVALUATION
By a □ physician □ psychologist □ social worker □ other: _____________________________ (In compliance with K.S.A. 59-3064)
Attach additional sheets as necessary.
(1) Date/Location of examination:_______________ , at ______________
(2) Name of proposed ward/conservatee:__________________________
(3) Year of Birth:_______
(4) Age at time of examination and evaluation: ______
(5) Description of (including the date of) any prior assessments, evaluations or examinations of the proposed ward/conservatee which were reviewed or relied upon in preparation for this examination or evaluation:
___________________________________________
(6) Results of this examination and evaluation:
___________________________________________
(a) description of proposed ward’s/conservatee’s physical condition:
___________________________________________
(b) description of proposed ward’s/conservatee’s mental condition:
___________________________________________
(c) description of the nature and extent of the proposed ward’s/conservatee’s cognitive and functional abilities and limitations: ___________________________________________
(d) description of any adaptive behaviors or skills, or other assistive technologies which the proposed ward/conservatee employs to alleviate his/her limitations:
___________________________________________
(e) prognosis for improvement of the proposed ward’s/conservatee’s limitations:
___________________________________________
(f) recommendations for treatment or rehabilitation, or for other measures which may improve or alleviate the proposed ward’s/conservatee’s limitations (taking into account the proposed ward’s/conservatee’s education and developmental potentials):
___________________________________________
(7) Names(s)/qualification of other professional(s) performing this examination and evaluation with you:
___________________________________________
(Name) (Title)
___________________________________________
(Name) (Title)
(8) Certification/opinion. I hereby certify under penalty of perjury that I/we have personally completed an independent examination and evaluation of the proposed ward/conservatee named above, and that this report contains an accurate summary of the results and findings of that examination and evaluation. Further information concerning these findings may be obtained by contacting__________________at______________. Based upon these findings, it is my/our opinion that the proposed ward/conservatee:
(Check as appropriate)
☐ has the capacity to meet essential needs for physical health, safety or welfare
☐ does not have the capacity to meet essential needs for physical health, safety or welfare, and is therefore, in my/our opinion, an adult/minor with an impairment.
☐ has the capacity to manage the estate
☐ does not have the capacity to manage the estate and is therefore, in my/our opinion, an adult/minor with an impairment
(9) Participation: It is further my/our opinion that the proposed ward/conservatee:
(Check as appropriate)
☐ should be able to participate in the court proceedings associated with this guardianship/conservatorship
☐ could not meaningfully participate in the court proceedings associated with this guardianship/conservatorship
☐ should not participate in the court proceedings associated with this guardianship/conservatorship because such would be injurious to the proposed ward’s/proposed conservatee’s health or safety.
____________________________________________________________
(Date) (Signature) (Title)
