Ind. Porter Cnty. Probate Rules App. D

STATE OF INDIANA )

COUNTY OF PORTER )

IN THE MATTER OF )

THE GUARDIANSHIP OF )

)

CAUSE NUMBER:

PHYSICIAN'S REPORT

, a physician licensed to practice medicine in the

State of Indiana, submits the following report on

, alleged incapacitated person, based on an examination of said person on the day of

, 20.

1. Describe the nature and type of the incapacitated person's disability:

2. Describe the incapacitated person's mental and physical condition; and, when it is

appropriate, describe educational condition, adaptive behavior and social skills:

3. State whether, in your opinion, the incapacitated person is totally or only partially

incapable of making personal and financial decisions; and, if the latter, the kinds of decisions

which the incapacitated person can and cannot make. Include the reason for this opinion.

4. What, in your opinion, is the most appropriate living arrangement for the

incapacitated person; and, if applicable, describe the most appropriate treatment or rehabilitation

plan. Include the reasons for your opinion.

5. Can the incapacitated person appear in court without injury to his/her health?

(yes/no) If the answer is no, explain the medical reasons for your answer.

I affirm, under the penalties of perjury, the foregoing representations are true.

Signature: Printed:

Street Address: City/State/Zip: Telephones:

This report must be signed by a physician. If the description of the incapacitated person's

mental, physical and educational condition, adaptive behavior or social skills is based on

evaluations by the professionals, all professionals preparing evaluations must sign the report.

Evaluations on which the report is based must have been performed within three (3) months of

the date of the filing of the petition.

Names and signatures of other persons who performed evaluations upon which this report is

based: Name:

Address:

Signature:

Name:

Address:

Signature: