REQUEST FOR MENTAL HEALTH CAPACITY EVALUATION

REQUEST INFORMATION

Date of Request: __________________________________________

Request Priority:
☐ Emergency (affecting immediate treatment decisions)
☐ Urgent (legal proceeding pending within 30 days)
☐ Standard

Type of Capacity Evaluation Requested:
☐ Capacity to make treatment decisions (informed consent)
☐ Capacity to execute advance directive/power of attorney
☐ Testamentary capacity (capacity to make a will)
☐ Contractual capacity
☐ Capacity for independent living
☐ Competency to stand trial (forensic)
☐ Guardianship/Conservatorship evaluation
☐ Capacity to refuse treatment
☐ Capacity to consent to research participation
☐ Other: _____________________________________________________

PART I: REQUESTING PARTY INFORMATION

Section A: Person Making Request

Name: _____________________________________________________

Relationship to Individual:
☐ Self (individual requesting own evaluation)
☐ Family member - Relationship: _______________________________
☐ Attorney for individual
☐ Attorney for other party
☐ Healthcare provider
☐ Social worker/case manager
☐ Court/legal system
☐ Adult Protective Services
☐ Other: _____________________________________________________

Organization (if applicable): ______________________________

Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

Bar Number (if attorney): __________________________________

Section B: Authority to Request Evaluation

Basis for requesting this evaluation:

☐ Individual has requested evaluation of their own capacity

☐ Court order - Case number: ___________________________________
Court: _____________________________________________________

☐ Statutory authority - Citation: ______________________________

☐ Healthcare facility protocol

☐ Legal proceeding requires capacity determination
Type of proceeding: _________________________________________

☐ Concern for individual's welfare/safety

☐ Other: _____________________________________________________

PART II: INDIVIDUAL TO BE EVALUATED

Section A: Identifying Information

Full Legal Name: __________________________________________

Other Names Used: _________________________________________

Date of Birth: ____________________________________________

Age: ______________________________________________________

Social Security Number (last 4 digits): ____________________

Gender: ___________________________________________________

Section B: Contact Information

Current Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

Current Location:
☐ Private residence
☐ Hospital: __________________________________________________
☐ Psychiatric facility: ______________________________________
☐ Nursing home/assisted living: _______________________________
☐ Correctional facility: _____________________________________
☐ Other: _____________________________________________________

Section C: Legal Status

Current Legal Status:

☐ No legal guardian/conservator - individual manages own affairs

☐ Has healthcare power of attorney
Agent name: ________________________________________________
Phone: _____________________________________________________

☐ Has general/durable power of attorney
Agent name: ________________________________________________
Phone: _____________________________________________________

☐ Under guardianship/conservatorship
Guardian/Conservator name: __________________________________
Phone: _____________________________________________________
Scope: ☐ Full ☐ Limited - Specify: _________________________

☐ Has representative payee
Name: ______________________________________________________

☐ Other legal arrangements: ____________________________________

Section D: Healthcare Providers

Primary Care Physician:
Name: _________________________________________________________
Address: ______________________________________________________
Phone: ________________________________________________________

Psychiatrist (if any):
Name: _________________________________________________________
Address: ______________________________________________________
Phone: ________________________________________________________

Other Mental Health Provider(s):
Name: _________________________________________________________
Specialty: ____________________________________________________
Phone: ________________________________________________________

PART III: REASON FOR EVALUATION

Section A: Specific Question(s) to Be Answered

Please specify the exact capacity question(s) you want the evaluator to address:

1. ____________________________________________________________
   ___________________________________________________________

2. ____________________________________________________________
   ___________________________________________________________

3. ____________________________________________________________
   ___________________________________________________________

Section B: Relevant Decision(s) at Issue

What specific decision(s) is the individual facing that requires capacity determination?

☐ Medical/Treatment Decisions
Specific treatment: ________________________________________
Provider recommending treatment: ____________________________
Urgency: ___________________________________________________

☐ Financial Decisions
Type of decision: __________________________________________
Amount involved: ___________________________________________
Deadline (if any): _________________________________________

☐ Legal Documents
Type of document: __________________________________________
Purpose: ___________________________________________________

☐ Living Arrangements
Proposed change: ___________________________________________
___________________________________________________________

☐ Other Decision:
___________________________________________________________
___________________________________________________________

Section C: Background and Concerns

Why is there concern about this individual's capacity?

☐ Recent change in cognitive function

☐ Diagnosis of dementia or cognitive disorder

☐ Active psychiatric symptoms affecting judgment

☐ Recent decisions that seem harmful or irrational

☐ Conflict among family members about individual's wishes

☐ Possible undue influence by third party

☐ Individual is refusing necessary medical treatment

☐ Individual is at risk of exploitation

☐ Legal proceeding requires capacity determination

☐ Other: _____________________________________________________

Describe specific observations or incidents raising capacity concerns:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

When did concerns about capacity first arise? _______________

Has the individual's functioning changed over time?
☐ Yes - Describe: ____________________________________________
___________________________________________________________
☐ No
☐ Unknown

PART IV: RELEVANT MEDICAL AND PSYCHIATRIC HISTORY

Section A: Current Diagnoses

Section B: Psychiatric History

History of psychiatric hospitalizations:
☐ None known
☐ Yes - Details:

History of mental health treatment:
☐ None known
☐ Yes - Type(s): _____________________________________________

Current psychiatric symptoms (if any):
☐ Depression
☐ Anxiety
☐ Psychosis (hallucinations/delusions)
☐ Mania
☐ Confusion/disorientation
☐ Memory problems
☐ Other: _____________________________________________________

Section C: Cognitive History

History of cognitive testing:
☐ None known
☐ Yes - When: ________________________________________________
Results: ___________________________________________________

History of dementia or cognitive impairment diagnosis:
☐ None
☐ Yes - Type: ________________________________________________
Date of diagnosis: _________________________________________

Section D: Current Medications

Section E: Substance Use

Current or recent substance use:
☐ None known
☐ Alcohol: ___________________________________________________
☐ Cannabis: __________________________________________________
☐ Opioids: ___________________________________________________
☐ Other substances: __________________________________________

History of substance use disorder:
☐ None known
☐ Yes - Substance(s): ________________________________________
Treatment history: _________________________________________

PART V: FUNCTIONAL INFORMATION

Section A: Current Level of Functioning

Activities of Daily Living (ADLs):

Instrumental Activities of Daily Living (IADLs):

Section B: Decision-Making Observations

Based on your observations, does the individual appear able to:

Describe observations supporting your answers:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PART VI: LEGAL CONTEXT

Section A: Pending or Anticipated Legal Proceedings

☐ No legal proceedings pending

☐ Guardianship/Conservatorship proceeding
Court: _____________________________________________________
Case number: _______________________________________________
Hearing date: ______________________________________________
Petitioner: ________________________________________________

☐ Will contest or estate litigation
Court: _____________________________________________________
Case number: _______________________________________________

☐ Contract dispute
Nature of dispute: _________________________________________
Court/case number: _________________________________________

☐ Criminal proceeding (competency to stand trial)
Court: _____________________________________________________
Case number: _______________________________________________
Charges: ___________________________________________________

☐ Involuntary commitment proceeding
Court: _____________________________________________________
Case number: _______________________________________________

☐ Other legal proceeding:
Type: ______________________________________________________
Court: _____________________________________________________
Case number: _______________________________________________

Section B: Court-Ordered Evaluation

☐ This evaluation is court-ordered

Attach copy of court order

Order date: ___________________________________________________

Deadline for evaluation: _______________________________________

Specific requirements in order: _________________________________
_______________________________________________________________

PART VII: COLLATERAL CONTACTS

Section A: Persons with Relevant Information

Please provide contact information for persons who can provide additional information about the individual:

Section B: Records Available

The following records are available for the evaluator:

☐ Medical records from: _______________________________________

☐ Psychiatric/mental health records from: _____________________

☐ Previous capacity evaluations

☐ Neuropsychological testing results

☐ Social work assessment

☐ Financial records

☐ Legal documents (power of attorney, will, etc.)

☐ Court records

☐ Other: _____________________________________________________

PART VIII: REQUESTED EVALUATOR QUALIFICATIONS

Section A: Evaluator Type Requested

☐ Psychiatrist

☐ Psychologist (licensed clinical)

☐ Neuropsychologist

☐ Geriatrician

☐ Neurologist

☐ Licensed Clinical Social Worker (for functional assessment)

☐ Other qualified professional: ________________________________

☐ No preference - qualified professional per state requirements

Section B: Special Requirements

☐ Evaluator must have specific board certification: ____________

☐ Evaluator must be approved by court

☐ Evaluator must be independent (no prior relationship with individual)

☐ Evaluation must include specific testing: ____________________

☐ Language requirement: _______________________________________

☐ Other requirements: _________________________________________

PART IX: STATE-SPECIFIC REQUIREMENTS

California

Capacity to Make Medical Decisions:
- Probate Code section 4609 defines capacity for healthcare decisions
- Must understand nature and consequences of proposed treatment, alternatives, and risks

Conservatorship Evaluations:
- Probate Code sections 1801-1898.5
- Requires evaluation by licensed physician or psychologist
- Must assess specific proposed powers

Declaration for Mental Health Treatment:
- Must have capacity at time of execution

Texas

Capacity Assessments for Guardianship:
- Probate Code section 687 requires physician's letter
- Must include specific functional limitations
- If basis is intellectual disability, requires psychological evaluation
- Evaluation must be within 6 months of hearing

Health Care Decisions:
- Health & Safety Code Chapter 166
- Capacity determination by attending physician

Florida

Guardianship Evaluations:
- Florida Statutes section 744.331
- Requires examination by committee of three professionals
- At least one must be psychiatrist or physician

Incapacity Determination:
- Must address each area of potential incapacity separately
- Report must follow statutory requirements

New York

Health Care Decision Capacity:
- Public Health Law section 2994-c
- Attending physician determines capacity
- Can require concurrence of another physician

Guardianship (Article 81):
- Mental Hygiene Law Article 81
- Court evaluator appointed to assess
- Focuses on functional limitations

PART X: AUTHORIZATION

Section A: Authorization for Evaluation

☐ Individual consents to evaluation

Individual's signature: _____________________________________
Date: ______________________________________________________

☐ Court has ordered evaluation (attach order)

☐ Legal representative authorizes evaluation

Representative's name: ______________________________________
Authority: _________________________________________________
Signature: _________________________________________________
Date: ______________________________________________________

Section B: Authorization for Release of Records

☐ Authorization for release of medical/psychiatric records to evaluator

I authorize the release of relevant medical, psychiatric, and other records to the capacity evaluator for purposes of completing this evaluation.

Signature: ____________________________________________________
Name (printed): _______________________________________________
Date: _________________________________________________________
Relationship to individual: ___________________________________

PART XI: CERTIFICATION OF REQUESTING PARTY

I certify that:

1. The information provided in this request is true and accurate to the best of my knowledge.

2. I have legal authority or a legitimate purpose to request this evaluation.

3. I understand that capacity is decision-specific and time-specific.

4. I understand this evaluation will be conducted by an independent professional and I cannot predetermine the outcome.

5. I will provide the evaluator with all relevant records and information requested.

Signature: ________________________________________________

Printed Name: _____________________________________________

Date: _____________________________________________________

Title/Relationship: _______________________________________

PART XII: EVALUATOR'S CHECKLIST (For Professional Use)

Upon receipt of this request, the evaluator should:

☐ Verify authorization for evaluation

☐ Review all relevant records

☐ Obtain collateral information

☐ Conduct clinical interview with individual

☐ Administer appropriate assessment instruments

☐ Consider decision-specific capacity standards

☐ Document findings thoroughly

☐ Provide clear opinion on capacity question(s)

☐ Submit report within required timeframe

Assessment Instruments to Consider:

☐ Mini-Mental State Examination (MMSE)

☐ Montreal Cognitive Assessment (MoCA)

☐ Aid to Capacity Evaluation (ACE)

☐ MacArthur Competence Assessment Tool (MacCAT)

☐ Hopkins Competency Assessment Test (HCAT)

☐ Capacity to Consent to Treatment Instrument (CCTI)

☐ Executive Interview (EXIT-25)

☐ Trail Making Test

☐ Clock Drawing Test

☐ Other: _____________________________________________________

IMPORTANT NOTES

Capacity is:
- Decision-specific: A person may have capacity for some decisions but not others
- Time-specific: Capacity may fluctuate and should be evaluated at relevant time
- Not the same as diagnosis: Having a mental illness or dementia does not automatically mean incapacity

The Four Abilities Model (Appelbaum & Grisso):
1. Understanding: Can comprehend relevant information
2. Appreciation: Can apply information to own situation
3. Reasoning: Can weigh options and consequences
4. Expression of Choice: Can communicate a decision

Burden of Proof:
- There is a presumption of capacity
- The party claiming incapacity typically bears the burden of proof

RESOURCES

American Bar Association - Commission on Law and Aging:
https://www.americanbar.org/groups/law_aging/

ABA/APA Assessment of Older Adults with Diminished Capacity Handbook:
Available through ABA website

National Center for State Courts - Capacity Resources:
https://www.ncsc.org/

This request form should be completed as thoroughly as possible to assist the evaluator. The evaluator may require additional information or records. Capacity evaluations should only be conducted by qualified professionals with appropriate training and credentials.