The undersigned evaluator hereby certifies the following as a report of the evaluation of the above named person, herein referred to as the "Patient," in support of the judicial appointment of a guardian, conservator, or both, for the Patient, and understands that this report may be submitted in a proceeding for such purpose.

    1. The undersigned understands that an "incapacitated person" is an adult who is incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements for his health, care, safety, or therapeutic needs without the assistance or protection of a guardian or (ii) manage property or financial affairs or provide for his or her support or for the support of his legal dependents without the assistance or protection of a conservator, and that an individual who displays poor judgment is not for that reason alone considered incapacitated within the meaning of this definition.

    2.  The undersigned understands that Virginia Code Section 37.1-134.11 (C) provides that in the absence of bad faith or malicious intent, a person performing the evaluation shall be immune from civil liability for any breach of patient confidentiality made in furtherance of his duties under this
section.

    3.  To the best information and belief of the undersigned:

        a. Patient is incapacitated.  A description of the nature, type and extent of the incapacity, including its attending, specific functional impairments, is set forth here:
 
 
 

        b. The diagnosis of the mental and physical condition of Patient, to the extent not set forth in the preceding paragraph, is set forth here:
 
 
 
 

    4. Patient is / is not on medication that may affect the actions or demeanor of the Patient.

    5. The undersigned is of the opinion that the Patient's ability to learn self-care skills, adaptive behavior and social skills is:

        a. nonexistent,
        b. low, or
        c. high.

    6. The prognosis for improvement by Patient is:

        a. excellent,
        b. good,
        c. fair, or
        d. poor.

    7. The date or dates of the examinations, evaluations and assessments of the undersigned upon which this report is based was, or were:

        Date(s): __________________________

    8. The undersigned is licensed as a:

        a. physician,
        b. psychologist,
        c. licensed clinical social worker, or
        d. ______________________________

    by the Commonwealth of Virginia, and is skilled in the assessment and treatment of the physical and mental condition of Patient for purposes of determining incapacity as defined above.

Printed name of undersigned: __________________________________________.