To the Physician and 1. General Information
The form tells you the court will use it to decide whether the person is incapacitated under the legal definition and needs a guardian. Enter your name and office details, confirm you are licensed in Texas, give the proposed ward's name, age and residence, and record the last examination date and setting. Confirm whether the person is under your continuing treatment and that you warned them communications are not privileged.
2. Evaluation of the Proposed Ward's Physical Condition
Give the physical diagnosis, mark severity as mild, moderate or severe, and describe the prognosis and treatment or medical history. The court reads the diagnosis against the incapacity definition in section 7: whether the person is substantially unable to provide food, clothing or shelter, care for their own physical health, or manage their financial affairs.
3. Evaluation of the Proposed Ward's Mental Functioning
Give the mental diagnosis with severity, prognosis and treatment history. If it includes dementia, answer whether placement in a secured dementia facility and dementia medications are in the person's best interest and whether they can consent to those medications. Then state whether improvement is possible and, if so, when the person should be reevaluated to see whether guardianship is still needed.
4. Cognitive Deficits
Check orientation to person, time, place and situation, then mark each area with a deficit: short-term and long-term memory, immediate recall, understanding and communicating, recognizing familiar objects and persons, problem solving, logical reasoning, grasping abstract aspects of the situation, interpreting idioms or proverbs, and breaking complex tasks into steps. Note whether impairment periods vary substantially in frequency, severity or duration.
5. Ability to Make Responsible Decisions
Answer yes or no for each decision: complex business and financial matters, a personal bank account (and whether deposits should be limited), driving, voting, marriage, choosing a residence, daily medications, basic ADLs with and without supports, instrumental ADLs, and consent to medical, dental, psychological and psychiatric treatment. Answer each item separately; the evaluation of capacity in section 8 refers back to these answers.
6. Developmental Disability and Determination of Intellectual Disability
State whether the person has a developmental disability and its cause: intellectual disability, autism, static encephalopathy, cerebral palsy, Down syndrome or other. Complete the Determination of Intellectual Disability box only if incapacity rests on intellectual disability and you examined under HHSC rules or are updating or endorsing a prior determination. It asks for the level of functioning and evidence of onset during the developmental period.
7. Definition of Incapacity and 8. Evaluation of Capacity
Using the Estates Code § 1002.017 definition printed on the form, state whether the proposed ward is incapacitated. If so, mark total or partial. For partial incapacity, list the guardian powers that should be limited with supports and services. Explain if you answered no to every decision in section 5 but find partial incapacity, or yes to any but find total incapacity.
9. Ability to Attend Court Hearing
Answer whether the proposed ward could attend, understand and participate in the hearing, whether you recommend they not appear because of their incapacities, and whether current medication affects their demeanor or ability to participate fully. Attach a separate explanation in section 11 if the answer needs more context.
10. Least restrictive placement and 11. Additional Information of Benefit to the Court
Choose the least restrictive appropriate placement: nursing home level of care, assisted living, group home, memory care unit, own home or with family, or other. Add any other concerns the court should know on a separate page. Sign and date, then print your name and license number.