Guardianship Conservatorship Of Mentally Retarded Person Clinical Team Report
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Guardianship Conservatorship Of Mentally Retarded Person Clinical Team Report Form. This is a Massachusetts form and can be use in Probate And Family Court Statewide.
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Tags: Guardianship Conservatorship Of Mentally Retarded Person Clinical Team Report, CJ-P 118, Massachusetts Statewide, Probate And Family Court
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court Department
Division
Docket No.
GUARDIANSHIP/CONSERVATORSHIP
OF MENTALLY RETARDED PERSON
CLINICAL TEAM REPORT
To the Honorable Justices of the Probate and Family Court:
The undersigned hereby certify under the penalties of perjury that they are: a registered physician; a
licensed psychologist; and, a social worker, each of whom is experienced in the evaluation of mentally retarded
persons and that they have personally examined
(name of proposed ward)
(street address)
(city or town)
(county)
(state)
(zip code)
on
(date of examination)
It is the opinion of this team that said ward:
GUARDIANSHIP
Is a mentally retarded person to the degree that he/she is incapable of making informed decisions
with respect to the conduct of his/her personal and financial affairs.
CONSERVATORSHIP
Is a mentally retarded person to the degree that he/she is incapable of making informed decisions
with respect to the conduct of his/her financial affairs.
Is a mentally retarded person of majority age who is - wholly - substantially -selfsupporting by means of his/her wages or earnings from employment or other financial
entitlement and it is the recommendation of this team that such property, to the extent
of the person's wages or financial entitlement, or $300.00 per month whichever is less,
shall be exempt from the powers of the Conservator.
(over)
c.g.f.
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(CLINICAL TEAM REPORT BACK)
Describe in detail the diagnosis leading to the aforementioned opinion (indicating the level of retardation and the types of
decisions which the proposed ward has sufficient mental ability to make):
Date
(signature of registered physician)
(PRINT name)
(PRINT name)
(address, including zip code)
Tel. No. (
(signature of licensed psychologist)
(address, including zip code)
)
Tel. No. (
)
(signature of social worker)
(PRINT name)
(address, including zip code)
Tel. No. (
)
Uniform Probate Court Practice XXII(A)
A clinical team report, when accepted, must be dated and the examination of the team members must have taken
place within one hundred and eighty days (180) prior to the filing of each petition, temporary or permanent, unless
the court for cause shown waives this requirement.
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