Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No. CLINICIAN'S AFFIDAVIT AS TO COMPETENCY AND TREATMENT In Re: Guardianship of: Division Middle Name First Name Last Name Proposed Incapacitated Person/Respondent I, , do hereby state to my best knowledge and belief: Last Name M.I. First Name 1. I am a licensed physician, certified psychiatric nurse clinical specialist, or other person so authorized by law to prescribe antipsychotic medication in Massachusetts. I am employed by . 2. I supervise the psychiatric treatment of Respondent who is a resident (Name of Facility) (City/Town) The Respondent is a (State) patient at (Apt, Unit, No. etc.) (Address) . year old male female who was admitted on . . On that date, and since that 3. I first consulted on the treatment of the Respondent on time, I observed the Respondent and reviewed the Respondent's medical records. I am familiar with the Respondent's case history. 4. I have conferred with the following clinical staff in rendering the opinions expressed in this affidavit: Name Title/Relationship 5. Respondent's clinically diagnosed condition is: 6. The Respondent was admitted or most recently treated under the following circumstances: 7. Respondent has had this condition for In the past the condition has been MPC 800 (6/17/11) days untreated weeks months years other: . treated as follows: page 1 of American LegalNet, Inc. www.FormsWorkFlow.com 5 8. The Respondent continues to suffer from the effects of the clinically diagnosed condition. Specifically, the Respondent's behavior is as follows: 9. It is my opinion that adequate treatment of this Respondent requires the administration of antipsychotic medication as set forth in this affidavit. COMPETENCY 10. I have discussed with the Respondent the risks and benefits of the proposed plan of treatment. It is my opinion that the Respondent does not have the present ability to make informed decisions with respect to personal affairs; specifically, those decisions regarding psychiatric treatment, including, but not limited to, the ability to make informed decisions regarding treatment with antipsychotic medication with the following exceptions, if any: 11. I base this conclusion on my observations and examination of the Respondent and upon the following specific facts noted in the course of those observations and examinations: 12. The Respondent is: currently accepting treatment with the following antipsychotic medication: MEDICATION DOSAGE AND DOSE RANGE actively refusing to accept treatment with antipsychotic medication. The Respondent's stated reasons are as follows: PROPOSED TREATMENT 13. The Respondent has has not previously been administered antipsychotic medication. If Respondent has been treated with antipsychotic medications, the history of that treatment is as follows: 14. The following is a list of antipsychotic medications which were administered to the Respondent but discontinued due to negative side effects or lack of efficacy: None. MPC 800 (6/17/11) As follows: page 2 of American LegalNet, Inc. www.FormsWorkFlow.com 5 15. The proposed antipsychotic medication treatment plan is as follows: MEDICATION DOSAGE AND DOSE RANGE As currently listed in Q. 12 Alternative Antipsychotic Medication: MEDICATION DOSAGE AND DOSE RANGE 16. The Respondent is currently exhibiting the following side effects from the antipsychotic medication: is not currently exhibiting any side effects from the antipsychotic medication. 17. The potential side effects of the proposed course of treatment are as follows: 18. The results I expect from use of this medication with the Respondent include the following: 19. Long term planning for the Respondent includes the following: 20. Describe in detail the plan for reduction of the administration of antipsychotic medications: MPC 800 (6/17/11) page 3 of American LegalNet, Inc. www.FormsWorkFlow.com 5 SUBSTITUTED JUDGMENT FACTORS PROGNOSIS WITHOUT TREATMENT 21. It is my opinion that if the proposed treatment is not provided to the Respondent, it is likely Respondent will continue to deteriorate or will have to remain as an inpatient for an undetermined length of time. 22. It is my opinion that the proposed treatment is essential to ameliorate the clinically diagnosed condition from which this patient currently suffers. PROGNOSIS WITH TREATMENT 23. The prognosis with treatment is fair guarded good. With treatment it is expected that the Respondent will continue to make progress remain stable, with the prospect of (check all that apply): increasing levels of independence; the ability to remain in the community; eventual discharge from the hospital to a community setting; or other: RISKS AND BENEFITS OF PROPOSED TREATMENT 24. The risks and benefits of the proposed medications and treatment have been described in previous affidavits which I have reviewed. The risks and benefits of any proposed new medications are: PATIENT'S RELIGIOUS CONVICTIONS 25. The Respondent's religion is . The Respondent's decision with regard to treatment as proposed in this affidavit is not affected by Respondent's religious beliefs or convictions. is affected by Respondent's religious beliefs or convictions as follows: IMPACT ON PATIENT'S FAMILY 26. The Respondent has: family who are involved and supportive of the Respondent's treatment, and cooperative with facility staff. Any unnecessary or prolonged hospitalization would be a burden on the Respondent's family. family who are involved in, but not supportive of the Respondent's treatment, for the following reasons: MPC 800 (6/17/11) page 4 of American LegalNet, Inc. www.FormsWorkFlow.com 5 no family involved in Respondent's care and treatment. no known family. 27. If Respondent were competent, Respondent's relationship with family would affect Respondent's decision regarding treatment in the following way: No effect. The following effect(s): PATIENT'S EXPRESSED PREFERENCES 28. The Respondent is currently: accepting treatment. refusing to accept treatment although there is no evidence to suggest that the Respondent has, at other times, rejected treatment or medication offered to assist Respondent in recovery from a disease, a spell of illness, or psychiatric illness. OTHER 29. Other information that Court should be aware of is: Signed under the penalties of perjury. Date Signature (Print name) (Address) (City/Town) (Apt, Unit, No. etc.) (State) (Zip) Primary Phone #: MPC 800 (6/17/11) page 5 of American LegalNet, Inc. www.FormsWorkFlow.com 5