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HomeMy WebLinkAbout95-00504 ., .. SHAWN MOORE, Alleged Incompetent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 95- ootf IN RE: ORDBR AND NOW, this -1Vf.u 01' COURT day of , 1995, upon review of the attached petition, a hearing is in this matter for "11U1l1lof ' the 1& fll day of ~ , 1995, at ~p.m., in Courtroom # ~ 0 , Cumberland County Courthouse, CarliSle, Pennsylvania. Personal service of this Order and accompanying Notice and Petition shall be caused to be made upon the alleged incapacitated person by Petitioner in accordance with the Mental Health/Mental Retardation Act, 50 P.S. Section 4406. Notice shall also be given to all other persons and entities required to be notified under the Code. Proof of service shall be furnished at the above-scheduled hearing. BY THE COURT, J. IN RE: SHAWN MOORE, Alleged Incompetent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 95- ORDER FOR COMMITMENT I. After hearing and consideration of Reports, Testimony, Etc. Attached this court finds that SHAWN MOORE is/is not retarded. This court finds that SHAWN MOORE is in need of residential/non- residential placement outside his home. II. In reaching it determination, this Court has found that: 1) SHAWN MOORE is/is not impaired in adaptive behavior to a significant degree and is functioning at an intel- lectual level two standard deviation measurements below the norm as determined by acceptable psychological testing techniques; and 2) The impairment and the resultant disability were manifested before the Respondent's 18th birthday and are likely to continue for an indefinite period; and 3) SHAWN MOORE because of his retardation does/does not present a substantial risk of physical injury to himself or physical debilitation as demonstrated by behavior within thirty (30) days of the petition which shows that he is unable to provide for, and is not providing for his most basic need for nourishment, personal and medical care, shelter, self-protective and safety and that provision for such needs is not available and cannot be developed or provided in his own home or in his own community without placement. III. Accordingly, the Court directs that committed to SHAWN MOORE be for: (Name of Facility) Inpatient Care Partial Hospitalization outpatient Care for a period not to exceed Entered this (Duration of commitment) day of , 1995, by the Court. By: Signature of Presiding Judge IN RE: : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION SHAWN MOORE, Alleged Incompetent : NO. 95- PETITION REOUESTING A DETERMINATION OF INCOMPETENCY And now, the Petitioner by her attorney, Robert L. O'Brien, Esquire, avers as follows: 1. Your Petitioner is Frances Moore, an adult individual residing at 128 Neil Road, Shippensburg, PA., 17257. 2. Shawn Moore is an adult individual currently residing in the care of his mother Frances Moore at 128 Neil Road, Shippensburg, PA., 17257. 3. Shawn Moore is a 23 year old with a long history of SUffering from behavior and seizure disorder. 4. Because of Shawn's behavior problems and seizure disorder, he has become a danger to himself and his parents. He lacks the ability to function properly outside of a controlled environment, and is unable to properly care for his needs of nourishment, personal and medical care, shelter, self-protection and safety. 5. The proposed guardian of the person and estate would be the petitioner Frances Moore and Arden Moore, his parents, who have no interest adverse to that of Shawn. TIlE' COURT or COHHbN PLEIIS OF COUNTY' TERM, 19 NO. PETITION FOR COHHITHENT Frances Moore hereby pet! tions this Court to order the xx exsmlna tion commitment to an appropriate facility for examination, observation and diagnosis invnediate of Shawn Moore (Neme of Person) Frances Moore (Name of Pet! tioner) is the Mother of reepondent. (Relation to Respondent) is II resident of Cumberland County (Ilame of county) Shewn Moore (Name of Reupondent) Shawn Moore (Name of Respondent) X hoe been examined by II physician who has not has found that .aid person i. mentally retarded. CIIECK APPLICABLE PIIRlIGRAPII x ATTIICIIED ARE TilE CERTIFICIITES OF II PIIYSICIIIN OR PIIYSICIIINS TO TilE EFFECT TlII\T TIlE RESPONDENT IS HENTIII.LY IlETIIRDED. CERI'IFICIITES OF II PIIYSICII\N OR PIIYSICII\NS lIRE NOT IITTI\CIIED DF-CIIUSEI b. The physician who is most familiar with the Respondent hI NI\HE Dr. petcash IIDDRESS Holy spirit Hospital, N. 21st street. Camp Hill. PA 17011 a. I beUevs that the Respondent is in need of residential placement for the following reasons I Shown is in need of 0 residential placement that will provide .. 24 hour su ervisiun needed tu rotect himself and uthers. Shawn alo disorder that is uncuntrolled bv medication. b. ~hbl. symptoms of retardation which demonstrate the Respondent's inability to provide for his/her basic needa for food. shelter, and safety have been exhibil:ed within the past thirty (30) days? Shawn exhibits a ression to tis I re 8 danRer to hinlsclf and others throul!.h iliA UI1c.ontrot 'pd n.ng~r nntl nggrpf:tntnn ft""" does not have the akillB to livp lndp-pl!ndpnt'ly in toll.. ,.nmmllnt..y '.. " ~ COHM:lNWEALTlI OF PENNSYLVANIA COUN'rY OF CUMBERLAND Shawn Moore , Petitioner in this IIllltter, bein9 duly sworn accordin9 to law, do dspoee and etate that I am Frances and Arden Moore 128 Neil of Road. Shippensburq. PA 17257 and that the facts set forth in the fore9oing Petition are true and correct to the best of my knOWledge, information, and belief. d ~;y]ii(} , Pet! t!oner (l, c.ffl C7LI SWORN 'It) AND SUBSCRIBED BEFORE HE, TIllS ...:?? DAY OF ; ---:- r L ')1 c:,'- , 19~... II' ----( . /. I . /. a >dJ/L/; /, . NOTARY PUBLIC / / .' , I .. v#' /\:'//..1t./;/ I l./ iI r ___IIU__.. . ,'" >>crr,',llIAJ. ,'l;Al' -, ~ \IIt.,~t~" ,... yqU)ltj :.q;Y'f r.;.....;r. ,;r C.'/l~~:! :.o;;o!.~1. :::b'i:('~'.7', Vr' ~..'. ~ ~'-,.o If t."'i ~J':.JlJO~N h"(;th$ ~:,: ~<'Idj: ~7 ~""'I :.........:.... .::' '0/ . CF:nTIFICII'I'I: or PIIYSI_~1I1l C-..rr~J 1J)tJ ..!t' rJ IpcJ~ 'i>,SOr<JL., NJS o~, t. F<rP>,....t, ~ P/S~ ..a j\1-R. - ~".:I-l.;,""DJ.'" I~. ~ E)fo~"-O ..~,,*,, Nllr.T he IIImle wilhln Lhreo -(3) cJ NIIKE or 11' IWI'lIm'I' IS m:Il'I'/lI.I,Y 1lI:'I'/llllllm - t:onunllmenL months or tho Cirnt certiCyiug exnminntion. P/lTIENT~ S 1)/hv,J DIITF. or F:XIIIUIlIl'rIOIl ob 127/ <i';- /lDDRESIl OF 1'/lTIF:NT I 1+M1r1',\vf,).eJ pJ'bt-"-o:Jl~Jt, J -Iu ,\ve..n. ~..r I..\,) e:./~ UiRtory oC i11nesR ns given by npplicant and other relevnnt inrormntion including report of psychologint H patienL in mentally retarded (Form is nLtached for Report of Psychologist) '2 3~ Ww\ 8 /2 ~~ eMC.dl?-l I /yAr) IIJ/O-uJ 6J.";Cpn'l,oJ .t-Nd-f:J~ ~ <1\.c.. d, ~J-t-J () { fr(,..J ota.f r tJfY;}rd o.IIl,,..} I WI ,1.:1 -1-0 ,..~::k/vtk ~ ~ . '!1- M~. rlc.J -l.o W,/J - t::Jbl'1../ ~ ~ .loA .l4.l"..>"'.(..Ij"""-v.s ht~e"",^ I,J d.aI'(T hJjtIt\JJ.h~ btAw,,,r ~ .Av...~ "",_I.t.II.\, p~vrr~ rtf2R.(,~ I ,u, ,.-il ~/ r~ ~~ (,,~~/~/.1l I'hysical and mental finding" nt the time of exnmlnation. pi #"40 l~. rJ.,...J,'.Jg- e...J-k,.<~lD" ~/l"f'~. t.<JP"I'lt,i~tMJh,J~. 1.J.e. 'S 0..J rrwt+pil. A€O,,rtlNd...~. -r:r-to~! frIV:J.&rJ, ~t<J... ~6~.cl.1rt.c.tN.:U '0' pll.eJ , " i..fl 1,(c..t..!L "1Lo~ J /1'l.'/trJ.,J,J! A-h~rt)/,idt;" I jJ~'()JL. 1(/ ~fkl -:>..,< S~ /1./ t..~J.;<-/,'P'-'(' II ~ofJ1 A)'h,..,.moJ.. ~6 , (T~~,^M'-M~~ In my proCessional opInion, tho patillnt ~oeJ oe doos not present a substantial risk of physical injury to himself or debilitation because of his retardation. In my professional opinion, the patient dDes ~does not requiro rosidential placement. III I certify that I am licon90d to practice medicine or osteopathy in Pennnylvania and thnt I have examined lhe patient with caro and diligence within one week prior to the dnte of this certifJcation. DIITE, ~ C,12;7 t-~" ()~ M) Signature of Physicinp I fI-<;l/~ 11'11\.0<1 /f-;lJt"t ~ IIddress of Physician @or 0.0. <;,..,.. I~,p;r ~ lIFFIVIIVIT TIlls affida'}ft must be sworn ~o or affirmed be foro a person authorized to administer oath Stato of (J"...."-L.......!.,,-oe-...... ,,-, ) ~ r )ss County of (J.V>'J~U a-...,..{ _ ) .. i d I m.,orn ue ny u y n fflrmed according to Inw doth depose and . say thllt the facts sot Corth in tho abovo applicatioll are truo to tho best of his knowledge and bolief. Sworn /lffirmed to and subscribod beforo me this OJ'1,1::: day of ~......- {.l -- , 19...z.L. I cerU ry tltat the sigllnl:uro to Lite Corogoill9 poti tioll J s gonuino, ~<A..-lL. .rRon ndmln,tnterlng oal.h. I r NOliUiul Seal Doroan J. Shick. Nolory Public r.nSI Pennsboto T "' Cumberland Counl I t;ornml!islon ~pircs AprU27. 199& -- S.anlcy E, Schnrldtr, Ed. D. DlrKtor. Culd.&ncc Maod,alr1 Il90 Poplar Church Road Camp Hill, PA 17011 1717173706917 Guidance Associates of Pit Branch Office 82 North Second St, Chambersburg. PA 17201 c .'3"~CI n S.Kh.., M.A. ychololi5t ondSI. II. PA 1720\ 391 17171!b3 PSYCHOLOGICAL EVALUATION Name: Shawn Moore Age: 17yrs 10mos 25days BID: 12/16/71 Occupation: Student Education: 8th Date of Evaluation: 11/9/89 REFERRAL INFORMATION. oShawn has been referred for an Individual Diagnos- tic Intellectual Evaluation to determine the presence of conditions which might adversely affect pertormancB,.in .Drk~related activities. A pre- vious intellectual evaluation on 10/4/87, Eesulted in 8 full scale IQ of 69 and a diagnosis of developmental organic mental retardation. Academ- ic achievement was at the 34d grade level or lower. Shawn also suffers from a seizure disorder and was further diagnDsed as having oppositional disorder of childhood. 'Through ~uly or '89 h~has received therapeutic services through the offices or Stephen Overcash, EdD. There have been psychiatric consultation$ .ith Harvey Shapiro, M.D. and follow-up with Or. Vanucci I 0 f Hershey. who lllon1l:0ra .th..,!,bUn .dhord,eJ:. ,Madications have included Tegretol and Mebaral. In sp te or special educational and therapeutic interventions behavior remains' impulsive, judgment is poor, and Shawn has relatively little insight into the reasons for his behavior. Bureau of Disability Determination P.O. Box R Wilkes-Barre, Penna. 1B703-9983 Adjudicator: B. Keyser INTERVIEW DATA AND OBSERVATIONS. Shawn was accompanied to the evaluation by his mother who provided much of the interview data. Shawn is a rel- atively shy young man of average height and build. He was somewhat hes- itant in his conversation and was very slow and deliberate with his re- sponses to test items. Shawn was cooperative throughout the testing and mannerly; behavior was appropriate without emotional outbursts. Shawn lives with his brother(age 18) and parents. He has received home- bound education last year and this year after failing to adjust to more structured programs. He was not abused or mistreated in his childhood. He is a member of Christ United Methodist Church in Shippensburg and states that he enjoys watching TV and bowling. He admits to angry out- bursts and not responding well to the work 'no.' Shawn does not use al- cohol or drugs and has not been in trouble with law enforcement authori- ties. For additional information please refer to the 00-164. TESTS ADMINISTERED. Wechsler Adult Intelligence Scale-Revised, psychia- tric Activities Assessment, Interview TEST RESULTS AND CLINICAL IMPRESSIONS. Wechsler results follow: Verbal IQ - 67 Performance IQ - 66 Full Scale IQ - 66 Counsellna . Pl)'choJoslcal T atIna · AIlar:r M&napma\t.. t.:fadIatlon/Custody · Utlgatlon ..- - - -,...._,.._.~ PSYCHOLOGICAL EVALUATTON: SHAWN MOORE / Verbal Tests In formation Digit Span Vocabulary Ar ithmetIc Comprehension Similarities Scaled Scores 2 2 4 3 3 5 Performance Tests Picture Completion Picture Arrangement Block Oesign Object Assembly Digit Symbol Scaled Scores 4 5 5 4 4 Shawn is currently functioning in the Mild Range of Mental Retardation on all measures of IQ. This result differs from the 1967 evaluation where performance skills were much higher than verbal skills. Regarding the verbal subtests, Shawn knew the colors in the flag/shape of a ball/ purpose of a thermometer but did not know how many months in a year/ where the sun rises, he was able to repeat three numbers in forward ser- ies from memory and three numbers in reverse order from memory, he knew full definitions for bed/ship/penny/repair and partial definitions for winter/breakfast/fabric, he could count 7 blocks and do simple one colu~n addition and subtraction in his head, he knew why we wash clothes and what tD do with an addressed and stamped envelope but he did not know why foods are cooked or why child labor laws are necessary, and he was 'able.to identify similarities between orange/banana, dog/lion, coat/suit, eye/ear, and north/west. Regarding the visual/motor(Performance) sub- tests, Shawn recognized missing details in six moderately complex pic- tures, arranged four pictures in proper sequence of a moderately complex social interaction, successfully duplicated three relatively slmple.block designs/one without prior demonstration by the examiner, received par- tial credit for puzzles of a person/profile/hand, and was abla to proper- ly match ~ymbol~ and numbers in an eye/hand speed/coordinatian task. SUMMARY AND CONCLUSIONS. Shawn is currently functioning in the Mild Range of Mental Retardation on measures of cognitive skills; emotional responses and social judgment and interaction are also significantly im- paired. Appropriate diagnoses appear to be Mild Mental Retardation(DSH III-R: 317.00) and Organic Personality Oisorder(DSM III-R: 310.10). Shawn can understand, retain, and follow simple instructions in a one- to-one supervised environment. He can sustain attention to perform sim- ple repetitive tasks in that same environment. He cannot relate appro- priately to others, including fellow workers and supervisors, in a work setting, and cannot tolerate the day-to-day work pressure of production demands, schedules, etc. He is not capable of managing his own funds. ~~. JI.. ./:I;-;.L_ A. A ug e H. Stecher, M~A. Licensed Psychologist -- -~ . II. SOCIAL FUNCTION INc". Ths capacity to Interact spproprlate,. ~nd communicate effectively with other individuals. Discussion should Include the quality. depth and reciprocity of relationships. Please discuss the following In detail: A. Ability to get along with others (e.g,. family, friends, neighbors): Friends do not come to the house. Neighbors say' "Get off our property." Can yell, hit, bieak things. Started hitting father with belt last week when threatened to take allowance away. B. Ability to initiate sociel contacts: This may have occured prior to the beginning of seizures at age 8. Not currently. C, Ability to communicate clearly: Marginal to adequate. Tends to mumble words. D. Interest and participation In group activities: No group activities in school or community. ".-:': ~'':?:;F)'1~ .:~~~.-:. ~;'N\L~ ._'~':.,....~' ;-':-1[.(:$,{" ')'1 ,"-j'-,." ~. .... ....t' ~ ,; ;~" r...t\.... ,< E. Social maturity: . . ~~:s e~nr~::e~~~gS and alcohol. No h1s~P.X;y' ,q,tn:Pf1ft~!!',~..':!',~Mr.t'" F. Interaction with persons In authority (e.g.. ability to follow Instruction.. respond appropriately to criticism): Has good zelationship with teacher and usually does homework. Re- acts strongly to "no" from parents; e.g. he put many extension cords together causing a household hazzard. G. Interaction with co.workers or peers: Constantly argues with brother, nieces and nephews; will sometimes push and grab a hold. H. Interaction with ths public: Initially answers telephone but then seems confused about what to say after that. Will sometimes answer door. Does not go to bank, post-office, or store unaccompanied. I. Please specifically discuss any history of altercations, BVictlons. firings and any other Incidents not listed above: Not Applicable except for continued inability to adjust to structured school settings. Page 2 ;_~.JlH, '. -' '. . .!. f .t PSVCHIATRIC ACTIVITIES ASSESS''''NT Applicant's Name Shawn Moore 290-48-7653 Social Security Number I, ACTIVITIES OF CAlLY LIVING: These Include adeptlve ectlvltles. In the context of the Indlvldual'l overalllltuatlon. the quality of these sctlvltles II evaluated by their Independence, appropriateness end e<<ectlveness. It II necessary to define the extent to which the Individual II capsble of Initiating and participating In activities Independsnt of lupervlslon or direction. Please describe the Indlvldual'l performance of the following In detail: A, Cleaning: Not limi ted . B. Shopping: Always needs assistance. C. Cooking: Cannot be trusted with Judgment beyond the complexity of making toast. ,,'.'..'.l;.j;1','; D. UsllllI public b",sportltlon: Does not use pUblic transportation because of poor social Judgf\lent. E. Paying bills: Not capable intellectually or emotionally of managing own money. Has never written a check. F. Maintaining a I1IIldence: No skills in this area. G. Personal grooming and hygiene: Self-managing, but is usually monitored during shower and baths because of seizure possibilities. DD.IM ,. .......,....,. .. ...._ ._ ,..-u..... .......u .,. ............ _,.......~ ..........""'.. ........"AIII.. " I N TIlB COURT or COHHON PLEAS OF COUNTY <: TERM, 19 NO. PETITION FOR COHHITHENT Frances Moore hereby peti tions this Court to order ths xx examina tion commitment to an appropriets facility for examination, observation and diagnoeie immediate of Shawn Moore (Name of Person) I. Frances Moore (Name of Petitioner) Is the Mother of respondent. (Relation to Respondent) is a resident of Cumberland County (Nama of County) Shawn Moore (Name of Rsspondent) I. a. Shawn Moore (Name of Respondsnt) I. X has been examined by a physician who has not has found that said person is mentally retarded. CHECK APPLICABLB PARIIGRIIPH x ATTIICIIED I\RE TilE CERTIFICIITES OF A PIIYSICIIIN OR PIIYSICIANS TO TIlE EFFECT TIIAT TIlE RESPONDENT IS HENTALLY RETARDED. CERTIFICATES OF II PIIYSICIlIN OR PIIYSICIlINS lIRE NOT ATTIICIIED BF.CIIUSE, 4. b. The physician who is most familiar with the Respondent iSI NAME Dr. Petcash ADDRESS Holy spirit Hospital. N. 21st Street. Camp Hill. PA 17011 , 5. a. I believe that the Respondent is in need of residential placement for the following reasons I Shawn is in need of a residential placement that will provide , 24 hour supervision needed to protect himself and others. Shawn also has 0 seizure disorder that is uncontrolled by medication, S. 1>. nh..L symptoms of retardation which demonstrate the Respondent's inabUity to provide for his/her basic needs for food. shelter. and safety have been exhibited within the past thirty (3n) days? Shawn exhibits BRR.rCBSion to his parents and oroncrty destruction. HilA"'" pr.Hwnfoa a dan~cr to .limsclf and otlicrs tllrOU211 1119 uncontrol1pd nnR~r nnd nggrPAafnn Dn~ does not have the Bkil1s to livf'! Independpntly in f"11P rnmmttnito), y . . ~e..J I?,o .!l' r;!. IPr)Ya.r '1>'P(<I.L..~.f Ory.,w'L rz.vn"..,ol,~ 'P/!t~ ..LI f\1 -R. - ",,,.::1 -k;,.. D~ ~ E):'''te-.JO.>..o ..~,"" IF 'W"IEN'f IS Hl~N1'IILI.Y JU::'flllUll';1J - Conunitmcnt NUS'f bo 111"<10 within throo -(3) cJ months of tho rlrst certifying examination. CF.RTIFrCATE OF PIIYSICIIIIl NAME OF PATIENT ~~ ~ hA'w,J DIITF. OF EXIIMINATION 0& 127/ 'i S- ADDRESS OF PATIENT I I-fvw<' rt'1{~~ p~",uJt,J -Iv i""t..n,1-.r~S"~rl!.. lIistory of illness as given by applicant and other relevant information including report of psychologist if patient is mentally retarded (Form is attached for Report of PsychologlBt) ? '.S~ Ww\ I 12 <f.>-~ p.-:LJuJtl<>.J ..~ /J J/fh,oI ed~(p""", ~4v~.r. ~ <:1\.L d. ~~ 0 ( /V'{,Jo#J r d'Qrs:J o';'u,,...) I /VII/oJ +0 ,..~:::kAak ~ to. '~ ,4.d,....Ik-J'/"O ~,J - t::Jl3I/-z../ ~ r; Jo(\ .ltt..,,....~jllfl"'<S ht~AN,"^ ,.... d.oI.& .cnjdf\JJ.h~ ~nr ~ -A.,.,.~ ^",_I..LII\/ ~vrl~ J't'I?NA-- I ,u, ,,-11"/ r~ "".Jot {"o;.r../~JJl Physical and mental findings at the time of examination. i r' I pi #.,"(1 '(j S Jo,.J. .',Jg--t,..~-4/- 12,.::>/~~ ' f-<J".t"~ ",1i(U/l,J~, t.J..e. 'S' 0,..) fM!+f'~ Ae:lJ/,H.{..,cl"'t, ~~.' '^th.&r~ .f:dMM. ~~.4..Jrt.c..~ ,,,c..t,..dJ.... 4'Ul3, 'T(t,1M..1~r;~~ . Prt)/,;c.;", ,.o~'oL. f<:t hfkJ ""~ ~<t.h"J..:>;",/~ II "~Rtb,.Jf,..,..,J.. rre:, I CT...~"..n.iM~~ In my professional epinion, the patient ~~ ~does not present a substantial risk of physical injury to himself or debilitation because of his retardation. In my professional opinion, the patient (t:les ~does not require residential placement. III I certify that I am licensed to practice medicine or osteopathy in Pennsylvania and that I have examined the patient with care and diligence within ono week prior to the date of this certification. DIITE. o~/~/~ ()~ '9 Signature of Physiciap, ~ /~ 11'1...<1/#o:l.l"',~ Address of Physician 8 or D.O, e.,.." I~/p;r ~- . AFFWIIVIT This affida'}ft must be sworn :0 or affirmed before State of tJ.........'-L.Jv-"-"-'- ^-- ) ~ ~ )ss County of (:.t.vn~J a-,...r:-L ) a person authorized to administer oath b i d I Aworn e ng u y affirmed according to law doth depose and . say that the facts set forth in the above application are true to the best of his knowledge and bolief. Sworn Affirmed me this d) '1'11:: to and subscribed before 0'- , 19 I' . day Of~, ~- I certl Cy that the signat:urn to the foregoing peti lion l!l genuine: ,/1-tt-... U~--S.-.. '_~<A.-IL Signal.urn of .roon ndmin.intcrlng oath. I [ Not.will SfJal Ooroon J. StUCk. Notary Public f:nsl Punnsbofo Twp.. Cumberland Count , r:ommi~i!Mn EAplfl!S April 27. t99~ v.. .. CERTIFICIITE OF' PIIYSICIIIN IF PIITIEN'r IS HEN1'IILLY IU::TIIRDED - Commitment NUST be mnue within three (3) months of the first certifying examination. NAME OF PIITIENT 5..10""''' /!- ;??Ct:'~_ IIDDIlESS OF PIITIEN'r /2,8" #<'tl.t?/, _'7'~1ty...r;(~ I DllrF. OF' EXIIMINI\TION ~/#S- lIistory of illness aB given by applicant and other relcvant informntion inclUding report of psychologist if patient is mentally retorded (F'orm is attached for Report of PsychOlogist) 2J/'fc> :1J.t.mH..t-;-:,? ~/ ~;1kr,~ b kAN,"';, /4~r"-;.,,t?~/ P ~?.......,. dJt:'~r- , ~~ ..w-~...../S" L. /"d:J' ~ ~k//..r,.{ul'';:~ ,..- c::;::; t? ~ j)x-- '&/pc;'", tPt.s__",6,,- #/,/,I-I"te:.bnrk ,It,,t', C, ;A/e: c4.." r- &~~../ ".{~ !?.tnrr iNO,,4- J;. Physical and mental findings at the time of examination.. ,/ P.. /~;'?".n,..N k/7' II .7/Av'?'"aP ~k/c~ ~.u../A ~ .PH/pr'"__~ //k'/,r! A",~ .5~ ttfu&J ~ rt't:;...,r ./ S":5 dw/h....r- .,K"!"",,,,- ~--t' /... /?c: .,(...J....... ~ / ~~.-r~r , /"'.I'FKr 4~ :;i-t!'vr'M"/7 /..../",rr~ In my profe~onal opinion, the patient ~~~ present a substantial docs/does not risk of physical injury to himself or debilitation because of his retardation. In my professional opinion, the patient 2>dr S doeS/does not require residential placement. III and the I certify that I am licensed to practice medicine or osteopathy in Pennsylvania that I have examined the patient with care and diligence within ono week prior to date of this certification. C ~~~"/.7/'__ ~ ~ n;:ri) or 0.0, yYgnature of P ysician 4(y ~,...,,t- /-h-h' c,.,. /k Address of Physician' DIITE: fZ7/95 /IF'FIDIIVIT This affidavit must be sworn to Stato of ~~'L County of ~L-n1. /,.ua-v..."-. or affirmed before a person authorized to administer oath ) ) ss ) being duly SWorn affirmed according to law doth depose and say that the facts set forth in the above application are true to the best of his knowledge and belief. Sworn Affirmed to and Subscribed before me this .:;;l, day of ~1<-JL- -- , 19...2.i:. I certify thnt the signature to the forcgoing poti tiol1 is genuine: iJ~_C':x- '-~<-.!e..- signntllrQ(~f pernon numinlnter.lng onth. Notarial Seal Doreen J. Shick, Nolary Public Eat! Pennlboro Twp" Cumberland Counly My Commission Ell'plresAprll 27, 1990 C! SHAWN MOORE, Alleged Incompetent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 95-::; 0'1 IN RE: ORDER FOR COMMITMENT I. After hearing and consideration of reoorts and testimonv this court finds that SHAWN MOORE is retarded. This court finds that SHAWN MOORE is in need of residential placement outside his home. II. In reaching it determination, this Court has found that: 1) SHAWN MOORE is impaired in adaptive behavior to a significant degree and is functioning at an intellectual level two standard deviation measurements below the norm as determined by acceptable psychological testing teChniques; and 2) The impairment and the resultant disability were mani- fested before the Respondent's 18th birthday and are likely to continue for an indefinite period; and 3) SHAWN MOORE because of his retardation does present a substantial risk of physical injury to himself or physical debilitation as demonstrated by behavior within thirty (30) days of the petition which shows that he is unable to provide for, and is not providing for his most basic need for nourishment, personal and medical care, shelter, self-protective and safety and that provision for such needs is not available and cannot be developed or provided in his own home or in his own community without placement. III. Accordingly, the Court directs that committed to Selinsarove Center for: SHAWN MOORE be xx Inpatient Care Partial Hospitalization Outpatient Care for a periOd not to exceed one (1\ vear Entered this Court. 18th day of , 19...,2L, by the By: ding Judge i;..', , , . ,', -, ~L~~ ' ~.' : 't-:]_"", i~-,.~ ~. f" ., I.' ~5( . :~iL . 1i'''-L.' f~~,' . ~~k;!-ii;:-~,; ~ . ~i{.; , " ':. : ,1-','- --. " '. " ","d'. . ,', " " : .., . ';:" .' ' .. ..:' .. . N. .. "<;,., ,;;'..,,:, '" ';, ""2 ~i'-' )F:,; 'I, c' .." , ,,~;:,: ~ ,:,. c,"", "ie, "c,' '" , H " , .. ' . ;;,e ,~,,, ':~~!c." "" "J" "i' ;}:,".:q .'.' ";~~ ' ,', ',;:: .,:, . ,", (, ,'; ".; ,i, ': ,,';;" " ' ' " ,': <'; o"~ "";, ' ,;~:,~~~,~,:"" 'i2",;:. .". '"1.,,' . ":~l. '", ,; ::' ,', :,,;;:.,< ';; U'" ,\g;;,,;, ~t~fJ~t~i/i,':; ":,, '" 'C',.'... ". :'1;," ;:::";':;"',.:... .. "', 'Xi::,:; , ' . ~, ". 'c'~l' 'iE.'"":i; ~' ; ,'''' "" ", " if ,: "H", ";: ' \', ~~: .' en" ", \ i,"~'" :" ',',';,; i i:", 'It!' 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