Ohio probate courts require this four-page evaluation with an application to appoint a guardian for an alleged incompetent adult, with an emergency guardianship application, and with a guardian's report. The evaluator answers 15 questions on diagnosis, mental status, physical impairment, decision-making, finances, living situation and prognosis. The statement is evidence for the court; it does not itself declare the person competent or incompetent.
For a new or emergency guardianship application, a licensed physician or licensed clinical psychologist completes and signs the whole form. For a Guardian's Report, the evaluator may also be a licensed independent social worker, licensed professional clinical counselor, developmental disability team, certified nurse practitioner or licensed clinical nurse specialist.
The applicant or attorney fills in the county, judge and case number. Read the definition of incompetent from R.C. 2111.01(D) printed at the top: mental impairment from illness, disability, intellectual disability or chronic substance abuse that leaves the person incapable of caring for self or property. Base your answers on personal observations and prior history from your treatment of or interaction with the person.
Check A (guardianship application), B (application for emergency guardianship) or C (Guardian's Report) and mark your profession. A and B allow only a licensed physician or licensed clinical psychologist. C also allows a licensed independent social worker, licensed professional clinical counselor, developmental disability team, certified nurse practitioner or licensed clinical nurse specialist. For B involving the person, attach Form 17.1A.
Print your name, title or profession and business contact details. Then record the dates and places of evaluation, the time you spent on it, how long the individual has been your patient and their language preference. Give the actual length of the treating relationship rather than the length of this one evaluation.
Answer yes or no; if yes, list each current medication with its dosage and purpose, continuing on page 4 if the space runs out. The form then asks whether there are signs of physical or mental impairment caused by the medications themselves.
If yes, give the diagnosis: intellectual or developmental disability with severity (profound, severe, moderate or mild), mental illness type and severity, substance abuse description, dementia type and severity, or other condition with type and severity. Continue on page 4 if more space is needed.
Mark yes, no or unknown for impairment of orientation, speech, motor behavior, thought process, affect, memory, concentration, comprehension and judgment. In question 7, describe each impairment you marked, with the specific findings that support it, continuing on page 4 if needed.
Describe physical impairments such as vision, mobility or hearing; special characteristics the court should consider; and any indication of abuse, neglect or exploitation. Questions 11 and 12 ask whether the person can manage activities of daily living and decisions about medical treatment, living arrangements and diet, and can manage finances and property. Explain every no.
Choose the recommended living situation: independent living, assisted living or group home, nursing home, memory care or lockdown unit, or other. Mark whether the condition is stabilized and reversible. Give your opinion: for a new application, guardianship established or denied; for an existing guardianship, continued or terminated. Then certify the evaluation date and sign with your printed name.
The addendum is only for a Guardian's Report, not an initial application. A licensed physician or clinical psychologist signs it to state, to a reasonable degree of medical or psychological certainty, that the ward's mental capacity will not improve. Page 4 holds additional comments continued from earlier questions and needs its own date and evaluator signature.
Download the current version from the source each time; forms change without notice.
Statement of Expert Evaluation
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
It depends on the filing. With a guardianship application or an emergency guardianship application, only a licensed physician or licensed clinical psychologist may complete it. With a Guardian's Report, the list widens to licensed independent social workers, licensed professional clinical counselors, a developmental disability team, certified nurse practitioners and licensed clinical nurse specialists.
No. The form states that it does not declare the individual competent or incompetent; it is evidence the probate court considers. Your answers on decision-making, finances, living situation and prognosis, and your opinion on whether a guardianship should be established, continued, denied or terminated, inform the court's own decision.
The probate court will not pay the fee for completing the evaluation unless the court orders otherwise. The form tells the evaluator to secure payment from the applicant or the guardian, so arrange payment with them rather than billing the court.
For a new guardianship application, the evaluation must be completed before the application is filed. When the statement supports a Guardian's Report, the evaluation must be conducted within three months before the date of the report, under R.C. 2111.49. Your signed certification includes the evaluation date.