Fillable Printable Medical Certificate Guardianship or Conservatorship Form
Fillable Printable Medical Certificate Guardianship or Conservatorship Form
Medical Certificate Guardianship or Conservatorship Form
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MPC 400 (11/1/10) CRMDSEG
MEDICAL CERTIFICATE
GUARDIANSHIP OR
CONSERVATORSHIP
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
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 an intellectually disabled person, do not use this
document. A separate Clinical Team Report is required.
INSTRUCTIONS FOR COMPLETION
To the registered physician, licensed psychologist, certified psychiatric nurse clinical specialist or a nurse
practitioner completing this document:
You must complete this document. If there is any information about which you do not have direct knowledge, you are
encouraged to make inquiry of such other persons as may be necessary to complete the entire form. These persons might
include other healthcare professionals and/or others acquainted with the individual (e.g., family members or social service
professionals). If you receive information from others, the names of those individuals must be listed in the Certification
Section and attribution identified.
If you are completing this form on the computer and additional space is required for any narrative section, the
section will expand to permit additional information. Do not use medical terminology and/or abbreviations without
explaining them in terms that a lay person can understand.
ALL OF THE ATTACHED PAGES AND SECTIONS CONTAINED THEREIN MUST BE COMPLETED.
To the Honorable Justices of the Probate and Family Court:
The undersigned hereby certifies under the penalties of perjury that I am:
a nurse practitioner with experience in the area of:
a certified psychiatric nurse clinical specialist.
a licensed psychologist.
a registered physician specializing in the area of:
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:
Last Name
First Name
Middle Name
(Address Line 1)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
Date(s) of Examination(s)
who resides at
on
Prior to examination, I informed the patient that communications would not be confidential.
No, Explain:
Yes.
.
(age)
.
Division
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1.
CLINICALLY DIAGNOSED CONDITION(S) THAT RESULT IN INCAPACITY
A.
Description of mental and physical condition
Describe the individual's mental and physical conditions necessitating the appointment of a guardian and/or
conservator, including the date of onset and disease course.
Stability of mental and physical condition and living setting
B.
In the past 90 days, has the individual's mental and/or physical condition changed?
Yes
No
Uncertain
I.
If yes, please explain:
Yes
No
Uncertain
In the past 90 days, has the individual's living setting (i.e. community, hospital, nursing facility) changed?
II.
If yes, please explain:
Prognosis for Improvement
C.
With reasonable medical certainty, within the next 90 days, is the individual's mental and/or physical conditions likely to
change substantially?
Yes
No
Uncertain
If yes, explain whether the condition is likely to worsen or improve, as well as if there are any aggravating factors that could
make the individual appear confused but could improve with time or treatment (e.g. delirium, acute medical illness, the
interaction of multiple medications, hearing loss, vision loss, bereavement, etc.):
If improvement is possible, the individual should be re-evaluated in
weeks.
D.
List all Medications (or attach list):
Name
Dosage/Schedule
If an anti-psychotic medication
indicate with a checkmark.
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Could any of these medications impair mental functioning:
Yes
No
Uncertain
If yes, explain:
INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS
2.
Alertness/Level of Consciousness
A.
Overall Impairment:
Non-Responsive
Severe
Moderate
Mild
None
Memory and Cognitive Functioning (e.g., memory, comprehension, reasoning, judgment, planning, insight)
B.
Overall Impairment:
Emotional and Psychiatric Functioning (e.g., mood, anxiety, psychotic, substance use and other disorder)
C.
Overall Impairment:
Severe
Moderate
Mild
None
Severe
Moderate
Mild
None
Describe how impairments in A, B, and/or C cause the individual to have an inability to receive and evaluate information or
make or communicate decisions:
GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR PHYSICAL HEALTH, SAFETY, AND
SELF-CARE
3.1
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.
Areas in which the individual is able to meet the essential requirements for physical health, safety, and self-care:
A.
Describe the individual's retained abilities and adaptive behavior for physical health, safety, self-care for which the
guardianship may be limited (e.g., ability to manage ADL's and IADL's such as health, hygiene, home, communication,
driving, leisure, social; functioning in the community; ability to express treatment choices and make medical decisions;
ability to complete any or some legal transactions).
Areas in which the individual is unable to meet essential requirements for physical health, safety, or self-care:
Describe the impairments in physical health, safety, and self-care for which the individual requires a guardian.
B.
If individual is unable to make any decisions for him or herself or is unable to meet any essential requirements for
physical health, safety, and self-care (i.e. requires a full guardianship), describe why:
C.
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CONSERVATORSHIP: INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY
3.2
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.
Areas in which the individual is able to manage property or business affairs effectively:
A.
Describe the individual's retained abilities and adaptive behavior for management of property and estate for which the
conservatorship may be limited (e.g., ability to manage allowance, bills, donations, investments, real estate, protect
assets, resist fraud).
Areas in which the individual is unable to manage property or business affairs effectively:
B.
Describe the impairments in the management of property and business affairs for which the individual requires a
conservator. Describe how the person has property that will be wasted or dissipated unless management is provided
and/or how protection is necessary to provide money for the support, care and welfare of the person or those entitled to
the person's support.
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:
C.
VALUES AND PREFERENCES
4.
Describe the individual's values, preferences, and patterns, including previously described preferences (e.g., under
durable power of attorney, advance directive, health care proxy, or living will documents), whether the individual accepts
or opposes the guardianship/conservatorship, where the individual prefers to live, what makes life meaningful for the
individual, and religious or cultural considerations.
SOCIAL NETWORKS AND RISK OF HARM TO SELF OR OTHERS
5.
Social Network Relationships
A.
Very good supportive network
Some support from family and friends
Limited or nonexistent support
Social Support (Check one)
Very good social skills
Good social skills
Poor social skills
Social Skills (Check one)
Nature of Risks
B.
Describe the significant risks facing this individual and specify whether these risks are due to this individual's condition
and/or due to another person harming or exploiting him or her:
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The individual's risk of harm to self or others is:
C.
Mild
Moderate
Severe
The likelihood of harm is:
Almost Certain
Probable
Possible
Unlikely
D.
RECOMMENDATIONS FOR LEVEL OF CARE/SUPERVISION NEEDED, INCLUDING HOUSING
6.
An institutional placement being pursued at the following:
A.
If none, skip to section 7; if yes, answer:
Psychiatric facility
Other facility
Nursing home/Rehabilitation
None
Uncertain
The individual requires the following level of supervision:
B.
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
Describe the specific reasons for placement and efforts made to preserve the person's social support system (e.g.
placement in community of residence or near family):
RECOMMENDATIONS FOR APPROPRIATE TREATMENT AND HABILITATION: The individual may benefit from:
7.
Educational potential, training, or rehabilitation
Yes
No
Uncertain
Technological assistance or accommodations
Mental health treatment
Occupational, physical, or other therapy
Home and/or social services
Medical treatment, operation or procedure
Other:
Describe any specific recommendations:
Uncertain
No
Yes
Uncertain
No
Yes
Uncertain
No
Yes
Uncertain
No
Yes
Yes
No
Uncertain
ATTENDANCE AT HEARING
8.
It would be clinically harmful for the individual to attend the hearing. Describe why:
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The individual is able to attend the court hearing
What accommodations, if any, would enable the individual to attend the hearing:
CERTIFICATIONS
9.
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:
Name
Title/Relationship
List any tests which bear upon the issues of incapacity and date of tests:
Test
Date
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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.
Signed under the penalties of perjury:
SIGNATURE OF CLINICIAN
Date
(Print name)
License type, number, and date
Office Phone:
(Address)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
Office Address:
