MPC 400 Medical Certificate

MEDICAL CERTIFICATE
GUARDIANSHIP OR CONSERVATORSHIP

Commonwealth of Massachusetts

The Trial Court

Probate and Family Court

Docket No.:

Division:

INSTRUCTIONS FOR COMPLETION

This document will be used by the Probate and Family Court in the process of determining whether to appoint a guardian and/or conservator to assume responsibility for this individual in some or all areas of decision making and functioning. If, however, a guardianship or conservatorship is being sought for a mentally retarded person, do not use this document. A separate Clinical Team Report is required.

To the Honorable Justices of the Probate and Family Court:

The undersigned hereby certifies under the penalties of perjury that I am:

a registered physician specializing in the area of:

a licensed psychologist.

a certified psychiatric nurse clinical specialist.

I am prepared to present a statement of my qualification to the Court by written affidavit or personal appearance if directed to do so.

I personally examined:

First Name Middle Name Last Name

Address Line 1 Apt/Unit City/Town State Zip

Date(s) of Examination(s):

who resides at

on

Prior to examination, I informed the patient that communications would not be confidential.

Yes.

No, Explain:

1. CLINICALLY DIAGNOSED CONDITION(S) THAT RESULT IN INCAPACITY

A. Mental and physical condition

B. List all Medications (or attach list)

Could any of these medications impair mental functioning: Yes No Uncertain

If yes, explain:

Check if the individual is on any antipsychotic medications that require a Rogers treatment plan.

C. Prognosis for Improvement

With time and/or treatment, mental functioning could: Worsen Improve Stay the same

If improvement is possible, the individual should be re-evaluated in weeks.

2. INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS

A. Alertness/Level of Consciousness

Overall Impairment: None Mild Moderate Severe Non-Responsive

B. Memory and Cognitive Functioning

Overall Impairment: None Mild Moderate Severe

C. Emotional and Psychiatric Functioning

Overall Impairment: None Mild Moderate Severe

3.1 GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR PHYSICAL HEALTH, SAFETY, AND SELF-CARE

If seeking guardianship of the person, complete section 3.1. If seeking only a conservatorship, do not complete this section. Limited Guardianship is preferred by the court; describe how the guardianship may be limited. Describe how the assessment was performed and give specific examples.

A. Areas in which the individual is able to meet the essential requirements for physical health, safety, and self-care:

Areas in which the individual is unable to meet essential requirements for physical health, safety, or self-care:

B. If individual is unable to make any decisions for him or herself or is unable to meet any essential requirements...

3.2 CONSERVATORSHIP: INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY

If seeking conservatorship of the estate and affairs, complete section 3.2. If seeking only a guardianship of the person, do not complete this section. Limited Conservatorship is preferred by the court; describe how the conservatorship may be limited. Describe how the assessment was performed and give specific examples.

A. Areas in which the individual is able to manage property or business affairs effectively:

B. Areas in which the individual is unable to manage property or business affairs effectively:

If the individual is unable to make any decisions about, and is unable to manage, any property or business affairs effectively (i.e. requires a full conservatorship), describe why:

4. VALUES AND PREFERENCES

5. SOCIAL NETWORKS AND RISK OF HARM TO SELF OR OTHERS

A. Social Network Relationships

Social Support (Check one): Very good supportive network Some support from family and friends Limited or nonexistent support

Social Skills (Check one): Very good social skills Good social skills Poor social skills

B. Nature of Risks.

C. The individual's risk of harm to self or others is: Mild Moderate Severe

D. The likelihood of harm is: Almost Certain Probable Possible Unlikely

6. RECOMMENDATIONS FOR LEVEL OF CARE/SUPERVISION NEEDED, INCLUDING HOUSING

A. An institutional placement being pursued at the following:

If none, skip to section 7; if yes, answer: Nursing home/Rehabilitation Psychiatric facility Other facility None Uncertain

B. The individual requires the following level of supervision:

Locked facility 24 hr. supervision Some None

Less restrictive placement options have been pursued: Yes No Uncertain

The placement is anticipated to be: Long-term Short-term Uncertain

7. RECOMMENDATIONS FOR APPROPRIATE TREATMENT AND HABILITATION

The individual may benefit from:

Educational potential, training, or rehabilitation Yes No Uncertain

Technological assistance or accommodations Yes No Uncertain

Mental health treatment Yes No Uncertain

Occupational, physical, or other therapy Yes No Uncertain

Home and/or social services Yes No Uncertain

Medical treatment, operation or procedure Yes No Uncertain

Other:

8. ATTENDANCE AT HEARING

It would be clinically harmful for the individual to attend the hearing. Describe why:

The individual is able to attend the court hearing

What accommodations, if any, would enable the individual to attend the hearing:

9. CERTIFICATIONS

This form was completed based on an in-person clinical evaluation of the individual:

who is is not a patient under my continuing care and treatment.

In addition to a clinical examination, other sources of information for this examination:

Review of medical record.

Discussion with health care professionals involved in the individual's care.

Discussion with family or friends.

Other

Names and titles/relationships of those individuals who assisted in preparation of this report:

List any tests which bear upon the issues of incapacity and date of tests:

This document must be signed and dated by the person completing it. It does not need to be notarized.

I hereby certify that the evaluation of diagnosis, cognition, and function is within the scope of my professional competence based upon my education, training, and experience. I further certify that this report is complete and accurate to the best of my information and belief.