Civil Capacity Evaluation Report (Guardianship, Testamentary, or Medical)

Report Date: [Date report finalized]

Evaluation Date(s): [Date(s) of evaluation sessions]

Location: [Evaluation location and setting]

Examinee Name: [Full name]

Date of Birth: [DOB]

Primary Language: [Language]

Interpreter Used: [Yes / No] (If yes, specify type, name/ID if available, and languages.)

Retaining Party/Requestor: [Court / Counsel / Agency / Other]

Referral Source: [Court order / Counsel letter / Agency request / Other]

Evaluator: [Name, credentials, license number, contact information]

Case Information: [Court, jurisdiction, case number, caption] (State not applicable if none provided.)

Referral Question(s)

[Exact capacity question(s) as received] (Reproduce verbatim in quotation marks. Identify the decision(s) and time point(s) at issue.)

Capacity Modules Requested: [Medical decision-making / Guardianship or conservatorship of person / Guardianship or conservatorship of estate / Testamentary capacity] (List all that apply.)

Evaluator Role and Disclosures

[Statement that this is a forensic, non-treatment evaluation; identification of client versus examinee; affirmation of objectivity and independence]

Prior relationships or conflicts: [Description of any prior contact with examinee or parties, or potential conflicts of interest; if none, state none]

Qualifications: [Relevant training, licensure, board certifications, and capacity evaluation experience]

Notice and Consent

[Documentation of what examinee was told about purpose, requester, intended uses, report recipients, and limits of confidentiality]

Participation: [Voluntary / Court-ordered] Examinee response: [Agreed / Partially agreed / Refused]

Refusals or limits: [Portions refused, what was explained, and impact on evaluation] (Omit if none.)

Legal Standard and Decision Context

Jurisdiction: [State/Province/Country]

Legal standard: [Statute or case law citation with date]

Elements of the standard:

• [Element 1]
• [Element 2]
• [Element 3]

(Add or remove elements as appropriate. If the legal standard was not provided, document efforts to obtain it and note any provisional clinical framework used pending confirmation.)

Sources of Information

• Records reviewed: [Document titles, providers, date ranges] (Note if critical records were requested but unavailable.)
• Interviews conducted: [Interviewees, roles, dates, durations, formats]
• Behavioral observations: [Settings and circumstances observed]
• Testing and measures administered: [Instruments and brief purpose] (Include performance validity measures if used.)
• Decision-specific materials presented: [Educational materials, consent forms, decision aids, teach-back prompts]

(When presenting contested facts throughout this report, label source as: observed, self-reported, collateral-reported, or documented in records.)

Methods and Procedures

Evaluation conditions: [Setting, fatigue, pain, medication timing, sensory or motor limitations, environmental factors]

Language and accommodations: [Language used; supports such as repetition, simplified materials, visual aids, teach-back, breaks, assistive devices, support person present]

Interview and testing: [Sequence and content focus of interviews; tests administered with rationale; any deviations from standard administration]

Behavioral Observations and Mental Status

• Appearance and behavior: [Grooming, hygiene, posture, motor activity, eye contact]
• Cooperation and effort: [Engagement, persistence, performance validity concerns]
• Speech and language: [Rate, volume, articulation, fluency, comprehension, word-finding]
• Affect and mood: [Range, reactivity, congruence; reported mood]
• Thought process and content: [Organization, coherence; delusions or overvalued ideas relevant to the decision]
• Perception: [Hallucinations or misperceptions] (Include only if relevant.)
• Cognitive functioning: [Attention, orientation, memory, executive functions, calculation, visuospatial abilities; note fluctuations during encounter]
• Reliability: [Consistency across sources and sessions; response validity indicators; factors limiting reliability]

Illustrative quotes: [Brief direct quotes demonstrating decisional abilities or deficits] (Use sparingly and in context.)

Relevant History

(Include only details directly supporting capacity analysis.)

• Medical/neurological: [Neurocognitive disorders, cerebrovascular disease, TBI, seizures, delirium risks, sensory impairments]
• Psychiatric: [Diagnoses, hospitalizations, psychosis, mood or anxiety disorders]
• Substance use: [Substances, patterns, recent use or withdrawal risks, treatment history]
• Medications: [Current medications with cognitive or behavioral effects; adherence]
• Functional trajectory: [ADL/IADL changes over time]
• Social and supports: [Living situation, caregivers, advance directives, POA]
• Legal/financial context: [Prior guardianship petitions, exploitation concerns, fiduciary arrangements]

Functional Status and Supports

• ADLs: [Bathing, dressing, toileting, feeding, ambulation, continence]
• IADLs: [Medication management, finances, shopping, cooking, housekeeping, transportation, communication]
• Safety: [Falls, wandering, self-neglect, exploitation risk, emergency response capacity]
• Healthcare navigation: [Appointment management, prescription refills, understanding instructions]
• Financial management: [Paying bills, budgeting, recognizing scams, record-keeping]
• Existing supports: [Informal caregivers, formal services, legal instruments, case management]
• Potential supports to enhance capacity: [Accommodations, assistive services, environmental modifications]

Medical Decision-Making Capacity Analysis

(Include only if referral requests capacity for a specific medical decision.)

Decision at issue: [Treatment / Procedure / Refusal / Disposition] (Identify time point.)

Information presented: [Condition, options, risks, benefits, alternatives, consequences of refusal; method and language level used]

• Expressing a choice: [Clear / Inconsistent / Unable] — [Evidence of clarity, consistency, stability]
• Understanding: [Evidence examinee can restate condition and options in own words]
• Appreciation: [Application to self; acknowledgment of illness and consequences; recognition of treatment role]
• Reasoning: [Ability to compare options, provide rationale, weigh risks and benefits consistent with values]

Voluntariness: [Presence or absence of undue pressure, fear, or external control]

Threshold: [Note if heightened certainty applied for high-stakes decision] (Include only if applicable.)

Opinion: [Capacity present / Capacity not present / Indeterminate] — [Impaired abilities if lacking capacity; supports that could remediate; reassessment timeframe]

Guardianship/Conservatorship Capacity Analysis

(Include only if referral requests evaluation for guardianship or conservatorship.)

Scope: [Guardianship of person / Conservatorship of estate / Both] — [Specific domains at issue]

• Essential needs with supports: [Abilities to meet health, safety, housing, financial, and personal needs with appropriate supports]
• Abilities retained: [Retained capacities with examples]
• Limitations: [Deficits with concrete examples; distinguish incapacity from unwise choices]
• Specific risks without intervention: [Foreseeable harms, likelihood, severity]
• Less restrictive alternatives: [Options tried or considered; why insufficient or sufficient]

Opinion: [Not indicated / Limited guardianship recommended / Plenary guardianship recommended / Insufficient information] — [Domains to retain versus transfer; triggers for restoration review]

Reversible contributors: [Interventions that could restore or enhance capacity; reassessment timeframe]

Testamentary Capacity Analysis

(Include only if referral requests evaluation of will-making capacity.)

Time point anchored: [Date of execution / Date of instructions / Retrospective]

Testamentary act and estate context: [Document type, asset categories, intended beneficiaries; unexpected inclusions or exclusions described neutrally]

• Understands nature of a will: [Observations and quotes supporting or refuting]
• Knowledge of property: [Awareness of assets and approximate value or categories]
• Natural objects of bounty: [Recognition of close relations and potential beneficiaries]
• Rational plan of distribution: [Coherent, stable rationale linking assets to beneficiaries]

Impact of conditions on elements: [Direct effects of psychiatric or cognitive conditions on above elements; diagnosis alone is insufficient]

Undue influence: [Susceptibility, opportunity, motive, corroborating indicators] (Include only if red flags present.)

Opinion: [Capacity present / Capacity not present / Unable to determine] — [If indeterminate, specify additional information needed]

Clinical Formulation

[Synthesis explaining functional strengths and weaknesses; working diagnoses; implicated cognitive domains; interaction with medical, psychiatric, and situational factors; expected course] (Link conclusions to functional evidence; do not determine capacity by diagnosis alone.)

Opinions and Conclusions

(Provide separate statement for each decision or domain evaluated.)

• Decision/Domain: [Specify] — Opinion: [Capacity present / Not present / Indeterminate] — [Impaired abilities or elements; key supporting findings; supports that could improve capacity; reassessment timeframe] (Include "to a reasonable degree of medical/psychological certainty" if jurisdictionally expected.)

(Add additional items as needed.)

Recommendations

• [Medical or psychiatric treatments to improve cognition]
• [Communication accommodations and decision aids]
• [Supported decision-making arrangements with safeguards]
• [Environmental or service supports]
• [Legal or administrative tools]
• [Reassessment plan and triggers]

Limitations

[Specific limitations affecting confidence in opinions: missing records, unavailable collateral, time constraints, acute illness, one-sided referral data, retrospective constraints, examinee refusal] (For each opinion, specify how limitations affect confidence.)

Signature

Evaluator Signature: [Signature]

Credentials: [Degrees, certifications]

License Number: [License number and jurisdiction]

Date Signed: [Date]

Attachments: [CV / Test score appendix / Records list / Decision aids used / Other] (List if applicable.)