The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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REPORT OF MONITOR

Docket No.

Commonwealth of Massachusetts
The Trial Court
Probate and Family Court

Division

In the Interests of:

Incapacitated Person

First Name

Middle Name

Last Name

1. The Monitor of the Treatment Plan for the Incapacitated Person is:

First Name

M.I.

Last Name

(Address)

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

Primary Phone #:

Relationship to Incapacitated Person

The Monitor was appointed on

The Monitor

is not

the Conservator.

(date)

and

is not

the Guardian.

The Incapacitated Person currently lives at

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

(Address)

which is a

Community Residence

DDS-operated Regional Center

DMH Facility

Nursing Facility

Private Home

Other:

3. The Monitor last met with the Incapacitated Person on

(date)

The following was specifically discussed with the Incapacitated Person:

The Monitor reviewed the Incapacitated Person's medical records, the Treatment Plan that was allowed by this Court on

(date)

and other relevant information, on

The Incapacitated Person's treatment with antipsychotic medications

is not

in compliance with the current

Court Order.

If the treatment is not in compliance with the current Court Order, please explain the non-compliance:

MPC 404 (8/30/19) RPTM

page

The Incapacitated Person is currently receiving the following antipsychotic medications:

ANTIPSYCHOTIC MEDICATION:

DOSAGE:

The Monitor is in agreement with the clinician's opinion that the Incapacitated Person continues to be unable to make
medical treatment decisions, and continues to need a court order for antipsychotic medication. The conditions and
circumstances that necessitated the Court's present Order do not appear to have changed substantially.

The Monitor has discussed the Incapacitated Person's present status and treatment needs with the treating clinician.

Yes. Specify what was discussed, whether in person or by telephone, and when.

No. Explain on what date efforts were made to contact the clinician, in detail, and whether the clinician's progress

notes were reviewed.

The Monitor has spoken with the Incapacitated Person's Residential and/or Day program staff, if any, and with other
treatment providers regarding the Incapacitated Person's present status and current treatment needs. Specifically, we
have discussed the following (indicate with whom, whether in person or by telephone, and on what dates):

I certify that a signed copy of this Report was provided to each of the following persons at least thirty (30) days prior to the
expiration of the current Treatment Plan:

Name

Relationship

Address

Manner*

Date

Counsel for the
Incapacitated Person

Moving Party

* Indicate if by hand delivery, first class mail, certified mail, or if by agreement, by e-mail or facsimile.

MPC 404 (8/30/19) RPTM

page

SIGNED UNDER THE PENALTIES OF PERJURY

I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.

Date

Signature of Monitor

Signature of Co-Monitor (if applicable)

MPC 404 (8/30/19) RPTM

page

Report of Monitor

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 3
Fields(s): 80
Average fields per page: 26
Reading Level: Grade 12
LIST Grouping(s): HE-03-00-00-00, ES-05-00-00-00, HE-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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form_body_page_mn was form1[0].BodyPage1[0].S1[0].Mn[0] (0.40 conf)
form_body_page_drop_list was form1[0].BodyPage1[0].S1[0].DropDownList1[0] (0.37 conf)
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form_body_page_apt was form1[0].BodyPage1[0].S2[0].Apt[0] (0.40 conf)
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form_body_page_phone was form1[0].BodyPage1[0].S2[0].Phone[0] (0.40 conf)
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form_body_page_check_box__5 was form1[0].BodyPage1[0].S5[0].CheckBox1[4] (0.39 conf)
form_body_page_check_box__6 was form1[0].BodyPage1[0].S5[0].CheckBox1[5] (0.39 conf)
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form_body_page_subform_table_row_cell__13 was form1[0].BodyPage1[0].#subform[11].Table1[0].Row[2].Cell2[3] (0.40 conf)
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form_body_page_subform_table_row_cell__16 was form1[0].BodyPage1[0].#subform[11].Table1[0].Row[3].Cell2[1] (0.40 conf)
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form_body_page_subform_table_row_cell__18 was form1[0].BodyPage1[0].#subform[11].Table1[0].Row[3].Cell2[3] (0.40 conf)
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We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02