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pageofMPC 400 (11/1/10)    CRMDSEGMEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIPCommonwealth 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 COMPLETIONTo 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 NameFirst NameMiddle Name(Address Line 1)(City/Town)(State)(Zip)(Apt, Unit, No. etc.)Date(s) of Examination(s)who resides atonPrior to examination, I informed the patient that communications would not be confidential.No, Explain:Yes..(age).DivisionMPC 400 (11/1/10)    CRMDSEGpageof1.CLINICALLY DIAGNOSED CONDITION(S) THAT RESULT IN INCAPACITYA.Description of mental and physical conditionDescribe 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 settingB.In the past 90 days, has the individual's mental and/or physical condition changed?YesNoUncertainI.If yes, please explain:YesNoUncertainIn the past 90 days, has the individual's living setting (i.e. community, hospital, nursing facility) changed?II.If yes, please explain:Prognosis for ImprovementC.With reasonable medical certainty, within the next 90 days, is the individual's mental and/or physical conditions likely to change substantially?YesNoUncertainIf 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 inweeks.D.List all Medications (or attach list):Name Dosage/ScheduleIf an anti-psychotic medication indicate with a checkmark.MPC 400 (11/1/10)    CRMDSEGpageofCould any of these medications impair mental functioning:YesNoUncertainIf yes, explain:INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS2.Alertness/Level of ConsciousnessA.Overall Impairment:Non-ResponsiveSevereModerateMildNoneMemory 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:SevereModerateMildNoneSevereModerateMildNoneDescribe 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-CARE3.1If 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.MPC 400 (11/1/10)    CRMDSEGpageofCONSERVATORSHIP:  INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY3.2If 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 PREFERENCES4.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 OTHERS5.Social Network RelationshipsA.Very good supportive networkSome support from family and friendsLimited or nonexistent supportSocial Support (Check one)Very good social skills Good social skillsPoor social skillsSocial Skills (Check one)Nature of RisksB.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:MPC 400 (11/1/10)    CRMDSEGpageofThe individual's risk of harm to self or others is:C.MildModerateSevereThe likelihood of harm is:Almost CertainProbablePossibleUnlikelyD.RECOMMENDATIONS FOR LEVEL OF CARE/SUPERVISION NEEDED, INCLUDING HOUSING6.An institutional placement being pursued at the following:A.If none, skip to section 7; if yes, answer:Psychiatric facilityOther facilityNursing home/RehabilitationNoneUncertainThe individual requires the following level of supervision:B.Locked facility24 hr. supervisionSomeNoneLess restrictive placement options have been pursued:YesNoUncertainThe placement is anticipated to be:Long-termShort-termUncertainDescribe 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 rehabilitationYesNoUncertainTechnological assistance or accommodationsMental health treatmentOccupational, physical, or other therapyHome and/or social servicesMedical treatment, operation or procedureOther:Describe any specific recommendations:UncertainNoYesUncertainNoYesUncertainNoYesUncertainNoYesYesNoUncertainATTENDANCE AT HEARING8.It would be clinically harmful for the individual to attend the hearing.  Describe why:MPC 400 (11/1/10)    CRMDSEGpageofThe individual is able to attend the court hearingWhat accommodations, if any, would enable the individual to attend the hearing:CERTIFICATIONS9.This form was completed based on an in-person clinical evaluation of the individual:whoisis nota 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.OtherNames and titles/relationships of those individuals who assisted in preparation of this report:NameTitle/RelationshipList any tests which bear upon the issues of incapacity and date of tests:Test DateMPC 400 (11/1/10)    CRMDSEGpageofThis 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 CLINICIANDate(Print name)License type, number, and dateOffice Phone: (Address)(City/Town)(State)(Zip)(Apt, Unit, No. etc.)Office Address:

Medical Certificate Guardian or Conservatorship

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): 7
Fields(s): 106
Average fields per page: 15
Reading Level: Grade 35
LIST Grouping(s): ES-00-00-00-00, ES-05-00-00-00, HE-00-00-00-00.

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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_ic was form1[0].BodyPage1[0].S1[0].ICT[0] (0.43 conf)
form_body_page__1 was form1[0].BodyPage1[0].S1[0].IS[0] (0.40 conf)
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form_body_page_hid_text_l_g__2 was form1[0].BodyPage1[0].HidText2[0].LG1[0] (0.45 conf)
form_body_page_hid_text_l_g__3 was form1[0].BodyPage1[0].HidText2a[0].LG1[0] (0.45 conf)
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form_body_page_r_text_field__1 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[0].TextField4[0] (0.41 conf)
form_body_page_r_text_field__2 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[0].TextField4[1] (0.41 conf)
form_body_page_table_r_subform_check_box__1 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[0].Subform6[0].CheckBox1[0] (0.38 conf)
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form_body_page_table_r_subform_check_box__2 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[1].Subform6[0].CheckBox1[0] (0.38 conf)
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form_body_page_r_text_field__6 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[2].TextField4[1] (0.41 conf)
form_body_page_table_r_subform_check_box__3 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[2].Subform6[0].CheckBox1[0] (0.38 conf)
form_body_page_r_text_field__7 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[3].TextField4[0] (0.41 conf)
form_body_page_r_text_field__8 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[3].TextField4[1] (0.41 conf)
form_body_page_table_r_subform_check_box__4 was form1[0].BodyPage1[0].Table1[0].Table1[0].R1[3].Subform6[0].CheckBox1[0] (0.38 conf)
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form_body_page_row_text_field__6 was form1[0].BodyPage1[0].Table2[0].Table[0].Row1[2].TextField4[1] (0.41 conf)
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form_body_page_text_field__13 was form1[0].BodyPage1[0].S28[0].TextField4[7] (0.41 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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