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9th Judicial District
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► This form is available to print in PDF or Word format at the bottom of this page.
REPORT OF EXAMINATION AND EVALUATION
By a □ physician □ psychologist □ social worker □ other: _____________________________ (In compliance with K.S.A. 59-3064)
Attach additional sheets as necessary.
(1) Date/Location of examination:_______________ , at ______________
(2) Name of proposed ward/conservatee:__________________________
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