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INSTRUCTIONS FOR COMPLETING THE CLINICAL TEAM REPORT FOR
GUARDIANSHIP AND/OR CONSERVATORSHIP
INTRODUCTION
The Clinical Team Report is a Probate and Family Court document that is used
to recommend guardianship for incapacitated persons and/or conservatorship for
persons to be protected concerning the management of property or business
affairs. It is used where an individual is alleged to have an intellectual disability.
Court orders that remove a person’s authority to make life decisions will be
limited to the extent necessary to protect the person from harm.
The Clinical Team Report has been developed to provide comprehensive and
detailed information to the Court by identifying areas in which the individual is
able to make informed decisions and areas in which he or she is not. Other
information the Report is designed to provide includes: information on the
severity of the disability, other conditions influencing decisionmaking ability,
intrusive interventions prescribed or proposed, risks to the individual, social
networks that may assist in decisionmaking and the individual’s ability to attend
the court hearing.
The following documents on the site may be particularly helpful to clinicians
preparing the Clinical Team Report:
• General Information regarding Guardianship/ Conservatorship MPC190
• Limitations to Guardianship and Conservatorship for Clinicians MPC 903a
• Clinical Team Report MPC 402
What is the legal standard for guardianship?
Under the new Uniform Probate Code, a guardian may be appointed for
an incapacitated person who, for reasons other than advanced age or
minority, has a clinically diagnosed condition that results in an inability to
receive and evaluate information or make or communicate decisions to
such an extent that the individual lacks the ability to meet essential
requirements for physical health, safety, or selfcare, even with
appropriate technological assistance.
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Appointment of a conservator or other protective order may be made in
relation to the estate and affairs of a person who is disabled for reasons
other than minority if the court determines that:
1) the person is unable to manage property and business affairs because
of a clinically diagnosed impairment in the ability to receive and evaluate
information or is unable to make or communicate decisions, even with the
use of appropriate technological assistance or because the individual is
detained or otherwise unable to return to the United States and,
2) the person has property that will be wasted or dissipated unless
management is provided or, money is needed for the support, care and
welfare of the person or those entitled to the person’s support, and that
protection is necessary or desirable to obtain or provide said money.
UPC Article V, Part 4, section 5401
GENERAL INSTRUCTIONS:
• The Clinical Team Report must be completed by a licensed psychologist,
•
physician and social worker, each of whom is experienced in the
evaluation of persons with intellectual disabilities.
It is expected that clinicians will review psychological assessments, test
reports and other relevant psychological evaluations prior to the
examination.
• Clinicians should include interview(s) of care providers most
knowledgeable with the Incapacitated Person.
• All sections of the Clinical Team Report must be completed by the
clinicians. Use brief, relevant statements. Sections must not be left blank.
Write “Not Applicable” if appropriate.
• Completion of the form electronically allows for the expansion of narrative
sections.
petition. §5306 (b)(5).
• The examination must have taken place within 180 days of the filing of the
• Completed Clinical Team Reports should be printed on quality bond paper
such as Southworth, Fine Linen Paper #564C (ivory).
IDENTIFYING INFORMATION:
• Accurate full name (including middle name) and address are required by
the court. Clinicians may wish to add date of birth.
• Prior to completion of the evaluation, the individual must be informed of
the purpose of the evaluation and the potential that the evaluation will be
used to form a legal finding of incapacity, removing the individual’s rights
UPC Article V, Part 1, section 5101(9)
What is the legal standard for conservatorship?
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to make personal or financial decisions in whole or part. The process of
disclosure and the person’s understanding of it should be documented in
the clinical
record. If you did not provide this disclosure to the individual for clinical
reason (e.g., the person is in a coma), check “No” and provide the reason.
SECTION 1: CERTIFICATION OF METHODS OF EVALUATION:
How do the clinicians document the sources of information used to
complete the Clinical Team Report?
• Clinicians should utilize records of intellectual, adaptive and other
previously completed relevant assessments.
• Clinicians should interview the individual and persons who know him/her
well.
• Check the appropriate boxes to indicate the type of information, e.g.,
assessment and/or interviews.
•
interviewed and test reports.
• State Intellectual Quotient(s) (IQs) found in the test reports.
In the spaces provided, state identifying information concerning persons
SECTION 2: CLINICALLY DIAGNOSED CONDITION(S) THAT MAY RESULT
IN INCAPACITY:
Does the person have an Intellectual Disability? Does the person have
other relevant diagnoses that may affect decision making ability?
A. A diagnosis of Intellectual Disability, formerly referred to as Mental
Retardation, must be demonstrated to consider recommendations for
guardianship or conservatorship. Intellectual Disability is characterized by
significant limitations both in intellectual functioning and in adaptive
functioning which occurred before age 18. If the diagnosis of Intellectual
Disability has been demonstrated, place a check mark in the appropriate box.
In the space provided identify the level of intellectual disability and comment
on its impact on capacity to make informed decisions.
B. You are being asked to comment only on concurrent diagnoses that
appear to affect decisionmaking ability. For example, schizophrenia or other
severe mental illnesses may substantially impact ability to make informed
decisions. If there are no concurrent diagnoses or diagnoses that do not
affect decisionmaking, write “not applicable”.
C. You are being asked to list only those medications that influence decision
making ability – whether positively or negatively. For example: Sideeffects of
some medications include confusion and problems with concentration. If that
is the case, state how the sideeffects make decisionmaking challenging for
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this individual. On the other hand, if a person carries a diagnosis of bipolar
disorder, but it is wellcontrolled with medication, indicate something like “as
long as the person is medication compliant, she/he is capable of making
considered decisions.” If there is no medication or no medication that affects
decisionmaking ability (positively or negatively), write “not applicable”.
D. Information should be provided on factors such as recent trauma, lack of
life experience or lack of education that currently impair decisionmaking but
that may improve or be mitigated through appropriate treatment.
SECTION 3: INTRUSIVE TREATMENTS PRESCRIBED/PROPOSED
“Substituted Judgment”
Is the person being prescribed an extraordinary treatment that may have
significant risk of dangerous side effects? If so, is the person incapable of
making an informed decision with respect to this treatment? If yes, then a
substituted judgment by the Court may be necessary.
Some guardianships are limited to decisions regarding treatment of a person with
mental illness with antipsychotic medications. These are commonly referred to as
“Rogers’ Orders.” 1
When answering the question in subsection A., i.e., “In your opinion is the
individual capable of giving informed consent to treatment with antipsychotic
medication?”, the only consideration for competency should be whether or not
the individual is able to make or communicate informed decisions regarding
antipsychotic medications. This is not the place for an opinion regarding whether
the individual needs antipsychotic medication.
Other areas where substituted judgment might be necessary are identified in
subsection B. Several examples of intrusive interventions and some
extraordinary medical treatments are listed. These and other interventions,
which have “profound implications”, require substituted judgment by the Court.
Again, it must be determined whether the individual can make an informed
decision regarding the specific procedure(s) being recommended.
1 Socalled “Rogers” orders came out of a 1983 Massachusetts Supreme Judicial Court case which
affirmed the right of hospitalized psychiatric patients to refuse antipsychotic medications in non
emergency situations. The Court stated that a“...patient is competent and has the right to make
treatment decisions until adjudicated incompetent by a judge.” And the court must then determine,
using the substituted judgment standard, that s/he would consent to the use of antipsychotic
medication. RUBIE ROGERS vs. COMM. OF THE DEPARTMENT OF MENTAL HEALTH 390
Mass. 489.
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SECTION 4: SOCIAL NETWORKS TO ASSIST IN DECISION MAKING
Does the person have friends or family members who typically help them to
understand and make decisions?
When answering this question, keep in mind that natural support is among the
less restrictive options to guardianship for individuals with intellectual disabilities.
Consider if the person appears clearly able to, or has a history of being able to:
Identify areas where s/he needs assistance with important life issues
Identify and contact specific individuals to get needed help
AND
AND
Has a history of seeking then regularly rejecting such support.
SECTION 5: RISK OF HARM TO SELF OR OTHERS
Would failure to appoint a guardian create an unreasonable risk to physical
health, safety or selfcare? If so, what are those risks and how severe and
likely are they to occur?
History, especially recent history, can be a helpful guide in considering risk of
harm. Has risk of harm been affected over time by treatment (e.g. mental health
services) or supports (such as supervision) and will that treatment or support be
maintained?
It is possible that there may be multiple risks to consider. If so, please explain in
the narrative section. In some cases you may want to answer sections 5 A, B,
and C as an aggregate rather than separately.
.
SECTIONS 6.1 AND 6.2:
RECOMMENDATION ON GUARDIANSHIP/CONSERVATORSHIP
Does the person have Intellectual Disability to the extent that they are
unable to make informed decisions and may be at substantial risk to
physical health, safety, selfcare or property without the appointment of a
guardian or conservator?
A. In each of sections 6.1A for guardianship and 6.2A for conservatorship
clinicians are asked to identify areas in which the individual is able to make
informed decisions. The document entitled “Limitations to Guardianship and
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Conservatorship for Clinicians MPC 903a” located on the website and noted in
the Introduction, can be helpful in identifying factors to consider for this section.
B. In each of sections 6.1B and 6.2B clinicians are asked to identify areas in
which the individual is unable to make informed decisions. Again the
(“Limitations”) document on the website may be a helpful resource.
C. Clinicians are asked to complete 6.1C and/or 6.2C with their
recommendations as to whether the individual is unable to make any informed
decisions for him or herself with respect to physical health, safety and selfcare,
i.e., guardianship.
AND/OR
Is unable to make any informed decisions to manage property or business affairs
effectively, i.e., conservatorship.
SECTION 7: ATTENDANCE AT HEARING
Would attendance at a court hearing place the individual at substantial risk
of physical or emotional harm?
The Probate and Family Court expects that individuals will attend guardianship
and conservatorship hearings unless medically or psychologically harmful. For
example, the person would suffer severe anxiety that would be exacerbated
having to wait for long periods of time or having to be in a crowded or unfamiliar
situation, such as a courtroom. Another example is someone who has a serious
medical condition requiring constant medical attention.
Clinicians are asked to describe accommodations that would enable the person
to participate in court. Examples of reasonable accommodations include
presence of trusted people, scheduling when the courtroom and halls are not
likely to be crowded and minimal time in the courtroom.
SECTION 8: SIGNATURES OF CLINICIANS WHO COMPLETED THIS FORM
Complete this section as indicated by the labels below each line. The form does
not need to be notarized. The “Date” of signature does not need to be the same
as the “Date of Examination”.
In most cases it is expected the signatures will be
completed after the examination date.
As each signatory has provided responses to those questions which relate to his
or her experience with and knowledge of the incapacitated person, once all
questions have been answered, the information can be merged to create one
comprehensive Clinical Team Report.
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The final version can then be presented to each signatory separately, probably
electronically, for review. Each signatory can sign the same signature page or,
the signatures may be in counterpart. If signed in counterpart, the separate
signature pages should be appended to the Clinical Team Report for submission
to the Court.
