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. American LegalNet, Inc. www.FormsWorkflow.com (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. American LegalNet, Inc. www.FormsWorkflow.com