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Page 1 of 2 Report on Petition for Appointment of Guardian 01/30/2013 ELEVENTH JUDICIAL CIRCUIT COURT McLEAN COUNTY, IL In the Interest of: Case Number: , an alleged disabled adult. REPORT ON PETITION FOR APPOINTMENT OF GUARDIAN 1. The undersigned, who is a physician licensed to practice medicine in all its branches in the State of Illinois, examined hereinafter called the Respondent, on 2. The nature and type of Respondent’s disability is: 3. The impact of the disability on Respondent’s ability to make decisions or function independently is: 4. My/our evaluation of the Respondent’s mental condition, physical condition, educational condition, adaptive behavior, and social skills are: Mental Condition: Physical Condition: Educational Condition: Adaptive Behavior: Social Skills: ---PAGE BREAK--- Page 2 of 2 Report on Petition for Appointment of Guardian 01/30/2013 5. Based upon my examination and evaluation of the Respondent it is my opinion that: Guardianship is not necessary. Guardianship of the person is necessary, the scope of which as reasons for are: Guardianship of the estate is necessary, the scope of which and reasons for are: 6. My recommendation as to the most appropriate treatment or habilitation plan and living arrangement for the Respondent, and the reasons therefore are: Signatures and Credentials of Evaluators: Printed Name Signature Date of Evaluation Licensed by the State of Illinois as: License Number: Printed Name Signature Date of Evaluation Licensed by the State of Illinois as: License Number: Printed Name Signature Date of Evaluation Licensed by the State of Illinois as: License Number: