MEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIP INSTRUCTIONS FOR COMPLETION Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division 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 decisionmaking 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. To 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 registered physician specializing in the area of: a licensed psychologist. a certified psychiatric nurse clinical specialist. a nurse practitioner with experience 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: First Name Middle Name (Apt, Unit, No. etc.) (City/Town) Last Name (State) (age) (Zip) who resides at (Address Line 1) on Date(s) of Examination(s) Prior to examination, I informed the patient that communications would not be confidential. Yes. No, Explain: MPC 400 (11/1/10) page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 1. CLINICALLY DIAGNOSED CONDITION(S) THAT RESULT IN INCAPACITY A. Description of mental and physical condition Describe the individual's mental and physical conditions necessitating the appointment of a guardian and/or conservator, including the date of onset and disease course. B. Stability of mental and physical condition and living setting I. In the past 90 days, has the individual's mental and/or physical condition changed? Yes No Uncertain If yes, please explain: II. In the past 90 days, has the individual's living setting (i.e. community, hospital, nursing facility) changed? Yes No Uncertain If yes, please explain: C. Prognosis for Improvement With reasonable medical certainty, within the next 90 days, is the individual's mental and/or physical conditions likely to change substantially? Yes No Uncertain If 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 in D. List all Medications (or attach list): Name Dosage/Schedule weeks. If an anti-psychotic medication indicate with a checkmark. MPC 400 (11/1/10) page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Could any of these medications impair mental functioning: If yes, explain: Yes No Uncertain 2. INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS A. Alertness/Level of Consciousness Overall Impairment: None Mild Moderate Severe Non-Responsive B. Memory and Cognitive Functioning (e.g., memory, comprehension, reasoning, judgment, planning, insight) Overall Impairment: None Mild Moderate Severe C. Emotional and Psychiatric Functioning (e.g., mood, anxiety, psychotic, substance use and other disorder) Overall Impairment: None Mild Moderate Severe Describe 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: 3.1 GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR PHYSICAL HEALTH, SAFETY, AND SELF-CARE If 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. A. Areas in which the individual is able to meet the essential requirements for physical health, safety, and selfcare: 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). B. 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. C. 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: MPC 400 (11/1/10) page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 3.2 CONSERVATORSHIP: INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY If 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. A. Areas in which the individual is able to manage property or business