REVIEW ORDER 
Antipsychotic Medication

Docket No.

Commonwealth of Massachusetts 
The Trial Court 
 Probate and Family Court

In the Interests of:

Division

First Name

Middle Name

Last Name

Incapacitated Person

After consideration of the submitted pleadings, it is Ordered that:

1.

The plan for administration of antipsychotic medication(s) to the Incapacitated Person as contained in the Clinician's 

Affidavit and Report dated

, the Clinician having examined the incapacitated

person on

(date)

(date)

, is approved.

Blood level testing, as appropriate, shall be administered in accordance with current clinical protocols.  Side effect 
medication(s) may be administered if clinically indicated.

2.

The approved Treatment Plan shall be reviewed on

at

A.M.

P.M.

This approval shall expire at 4:00 P.M. on that date unless sooner extended.

(date)

3.

The Monitor,

, shall continue to monitor the Incapacitated Person

and file a written report to the Court for the next scheduled review hearing which sets forth the following:

(name)

A. Where, and in what circumstances the Incapacitated Person is currently living;

The substance of the Monitor's meeting with the Incapacitated Person;

B.

C.

D.

E.

F.

The Monitor's review of the treating clinician's Court-ordered treatment reports in terms of completeness and 
responsiveness to the Court's Order as well as consistency with the Incapacitated Person's medical records;

Types and dosages of all medications administered to the Incapacitated Person and whether or not administration of 
the authorized medications is in compliance with the Court's Order;

Whether the Incapacitated Person remains incapable of making medical treatment decisions and whether the 
conditions and circumstances which justified the Court's present Order authorizing treatment with antipsychotic 
medication and other medications have substantially changed;
The substance of the Monitor's interview of the treating clinician, whether in person or by telephone, regarding the 
Incapacitated Person's present status and treatment needs, and, if the treating clinician is/has been unavailable to 
the Monitor, details of attempts to contact the treating clinician should be outlined with specificity and the clinician's 
progress notes may be referred to instead;

G.

The substance of the interview of associated staff, whether in person or by telephone, regarding the Incapacitated 
Person's present status and treatment needs.

4.

The parties shall comply with a stipulation or agreement of the parties dated

which is filed with the Court and expressly made part of this Order.

(date)

5.

Other:

Date

AT ANY TIME, ANY INTERESTED PARTY MAY MOVE TO ALTER, EXPAND, LIMIT OR TERMINATE THIS ORDER.

JUSTICE

JUDICIAL DESIGNEE

MPC 827 (8/30/19)

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