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Here is the text we could read:

INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT 

To establish incapacity, the petitioner must present testimony from an individual          

qualified by training and experience in evaluating persons with incapacities of the type alleged    
by the petitioner.  As an accommodation to such expert witnesses, the court may accept a       
complete and legible expert report in accordance with the attached form in lieu of expert         
testimony, whether in person or by deposition, unless otherwise required by rule or order of court.    

Form G-06 Effective June 1, 2019

COURT OF COMMON PLEAS OF  
________________________ COUNTY PENNSYLVANIA 
ORPHANS’ COURT DIVISION 

EXPERT REPORT 

RE: _______________________________________________________________________           

          An Alleged Incapacitated Person (AIP) 

No. ____________________     

PART I: PROFESSIONAL BACKGROUND (You may attach your  cur r iculum vitae, if it pr ovides an-
swers to Questions 1 through 5.  Please answer those questions not covered by curriculum vitae.)  

1. Name: _______________________________________         Title: _______________________________ 

2. Professional Address: ___________________________________________________________________

3. Complete education information:

Name of Institution 

Type of Degree Received 

Date Completed 

Undergraduate 

Graduate 

Post-Graduate 

4. Do you have any active professional licenses?         Yes         No

If yes, indicate in what state or states you are licensed as well as the date(s) issued.
______________________________________________________________________________________

______________________________________________________________________________________

List any board certifications: ______________________________________________________________

5. An Incapacitated Person is legally defined as: An adult whose ability to receive and evaluate information

effectively and communicate decisions in any way is impaired to such a significant  extent that he/she is
partially or totally unable to manage his/her financial resources or to meet essential requirements for his/
her physical health and safety.

Do you have experience evaluating whether or not an individual is incapacitated?         Yes         No

If yes, indicate the basis of your experience:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Form G-06 Effective June 1, 2019

p. 1 of 5

PART II:  ALLEGED INCAPACITATED PERSON (AIP) 

6. a.  Have you treated, assessed, or evaluated the AIP?

 Yes  No

b. Indicate the date(s) and location of any treatment, assessment, or evaluation you have provided or made

over the last two (2) years:
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

c. If 6a. is yes, what tests have you or others administered, e.g., mini mental status exam (MMSE),

Montreal Cognitive Assessment (MOCA), St. Louis University Mental Status Exam (SLUMS), etc.?
List dates administered and the score.  (Attach test results, not just the score.)
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

7. What is the present condition of the AIP?  List all known medical and psychiatric diagnoses and current

symptoms. (You may attach a list from your records.)

Diagnosis 

Symptoms/Manifestations 

8. List all known medications, including over-the-counter, that the AIP is taking.  For each known medication,
indicate, if known, the prescribing physician and the diagnosis for which the medication was prescribed or
the reason for taking.  (You may attach a list from your records.)

Medication 

Diagnosis/Reason Taken 

Prescribing Physician 

Form G-06 Effective June 1, 2019

p. 2 of 5

9. Indicate the AIP’s ability to perform the following functions:

Unimpaired 

Help               

Needs Some 

(Explain in #10 ) 

Totally           
Impaired 

Not Assessed 
or Not Enough         

Information  

Receiving and evaluating information     
effectively  

Communicating decisions 

Ability to give informed consent 

Short-term memory 

Long-term memory 

Activities of daily living 

Managing finances (including paying bills, 
making deposits, withdrawals and working 
with financial institutions) 

Managing health care (including following 
doctor’s orders and managing/taking     
medications) 

Providing for physical safety 

Responding to emergency situations 

Ability to resist scams 

10. For any response in Question 9 where the AIP “needs some help,” please describe the type and extent of

assistance needed.
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

11. What recommendations have you made or would you make concerning services necessary to meet the

essential requirements for the AIP’s physical health and safety?
______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Form G-06 Effective June 1, 2019

p. 3 of 5

12. What recommendations have you made or would you make concerning management of the AIP’s

finances?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

13. As indicated in Question 5, an Incapacitated Person is legally defined as: An adult whose ability to

receive and evaluate information effectively and communicate decisions in any way is impaired to such a
significant extent that he/she is partially or totally unable to manage his/her financial resources or to meet
essential requirements for his/her physical health and safety.

In your expert opinion, within a reasonable degree of professional certainty and based on your knowledge,
skills, experience, and education, is the AIP incapacitated?

 Yes, totally impaired

 Yes, partially impaired

 No

14. In your opinion, the most appropriate, least restrictive living situation for the AIP is (check one):

 The AIP can be left alone without supervision
 Home (       with part-time home health aide or

 24/7 assistance) 

 Independent living facility (room and board provided, emergency services readily available)
 Assisted living facility (room and board provided, assistance with some activities of daily

living)

 Secure facility (Alzheimer’s/Mental Health for safety and basic needs)
 Skilled nursing facility

15. If your responses in Question 9 indicated that the AIP is totally impaired or “needs some help”, do you

expect the AIP’s abilities in the next 6 months to (Check best estimate):
 Stay the same   

  Improve 

  Decline

 

Please explain:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

PART III: GUARDIANSHIP AND SERVICES 

16. Are you aware of any circumstances, medical or otherwise, that create a need for the appointment of an

emergency guardian for the AIP?

 Yes 
 
If yes, indicate reasons:
______________________________________________________________________________________

  No

      ______________________________________________________________________________________ 

      ______________________________________________________________________________________ 

Form G-06 Effective June 1, 2019

p. 4 of 5

__________________________________________________ 
Name (type or print) 

__________________________________________________ 
Address 

__________________________________________________ 
City, State, Zip 

__________________________________________________ 
Telephone 

__________________________________________________ 

Email 

17. The AIP is required to be at the hearing, absent circumstances that could cause harm to the AIP.  Putting

aside whether the court proceeding may be moderately upsetting to, confusing to or not understood by the
AIP, do you believe that the AIP’s presence at the hearing would cause harm to the AIP’s physical or
mental condition?

 Yes

 No

____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 

Indicate reason for response:  

  _

18. Please provide any additional information that could assist the court in determining incapacity.

 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that 
this verification is subject to the penalties of 18 Pa.C.S. § 4904 relative to unsworn falsification to authorities.  

______________________________ 
Date 

__________________________________________________ 
Signature 

Form G-06 Effective June 1, 2019

p. 5 of 5

(Untitled)

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 6
Fields(s): 159
Average fields per page: 26
Reading Level: Grade 10
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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date_completed_undergraduate
type_degree_graduate
date_completed_graduate
type_degree_received_graduate
date_completed_post_graduate
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part_iii_q__2
part_iii_q_n__2

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