Ccp 0211 Form – Fill Out and Use This PDF

CCP 0211 A (12/01/20)

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

COUNTY DEPARTMENT, PROBATE DIVISION

File No.

Estate of

Alleged Person with a Disability

REPORT OF PHYSICIAN

, a licensed physician, submits the following Report on

[printed name of the physician]

, an alleged person with a disability (the “Respondent”), based

[printed name of the alleged person with a disability]

upon evaluations of the Respondent performed on

.

NOTE: The evaluations upon which this Report is based must have been performed within three (3) months of the date the Petition for guardianship is filed.

1.The following is a description of the nature and type of the Respondent’s disability and an assessment of how the disability impacts on the ability of the Respondent to make decisions or to function independently, including an underlying diagnosis and a description of the manifestations of the disability:

2.The following is an analysis and the results of evaluations of the Respondent’s mental and physical condition, and (if appropriate) a description of the Respondent’s educational condition, adaptive behavior and social skills:

3.The following is my opinion as to whether guardianship is needed, the type and scope of the guardianship needed, and

the reasons for my opinion, including whether the Respondent is totally or only partially incapable of making personal and financial decisions and if only partially, the kinds of decisions which the Respondent can and cannot make:

4.The following is my recommendation as to the most suitable living arrangement for the Respondent and (if appropriate) the treatment or habilitation plan for the Respondent, and the reasons for my recommendation:

IRIS Y. MARTINEZ, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

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CCP 0211 B (12/01/20)	File No.

If the description of the Respondent’s mental, physical and educational condition, adaptive behavior or social skills is based upon evaluations by other professionals, all professionals preparing evaluations must also sign this Report.

5.The following are the names, addresses, certifications, licenses or other credentials, and signatures of each other person who performed an evaluation upon which this Report is based:

a.Name ______________________________________________________________________________________

Address ____________________________________________________________________________________

License (state and number)_____________________________________________________________________

Certification ________________________________________________________________________________

Other credentials _____________________________________________________________________________

Signature ___________________________________________________________________________________

b.Name ______________________________________________________________________________________

Address ____________________________________________________________________________________

License (state and number)_____________________________________________________________________

Certification ________________________________________________________________________________

Other credentials _____________________________________________________________________________

Signature ___________________________________________________________________________________

*

[signature of the physician preparing this Report]

[license (state and number)]

[address of the physician]

[city/state/zip]

[physician’s telephone]

Certification ________________________________________________________________________________

Other credentials _____________________________________________________________________________

*This Report must be signed by a licensed physician.

IRIS Y. MARTINEZ, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

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