Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. MEDICAL CERTIFICATE-GUARDIANSHIP INSTRUCTIONS FOR COMPLETION This document will be used by the Probate and Family Court to determine whether to appoint a guardian to assume responsibility for this individual in some or all areas of decision making. To the registered physician, licensed psychologist, or certified psychiatric nurse clinical specialist 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 might include other healthcare professionals and/or others acquainted with the individual (i.e. 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 or listing of medications, etc., the section will expand to permit additional information. If you are completing it in longhand, please attach additional pages as necessary. Do not use medical terminology and/or abbreviations without explaining them in terms which a lay person can understand. ALL OF THE ATTACHED PAGES AND SECTIONS CONTAINED THEREIN MUST BE COMPLETED. This document must be signed and dated by the person completing it. It does not need to be notarized. 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 I am prepared to present a statement of my qualifications to the Court by written affidavit or personal appearance if directed to do so. I personally examined who resides at PRINT name of proposed ward on Street Address City/Town State The duration of the most recent examination was Date(s) of Examination(s) . In my opinion, as described in detail in the attached sections, this individual: is a person incapable of caring for his/her personal and/or financial affairs due to mental illness. is a person unable to make or communicate informed decisions due to physical incapacity. Further, it is my opinion that this person is in need of: limited guardianship, as follows: full guardianship. If full guardianship checked, please explain why a limited guardianship would not be sufficient: CJ-P 112 (3/08) American LegalNet, Inc. www.FormsWorkflow.com . 1. PHYSICAL AND MENTAL CONDITIONS A List Physical Diagnoses and Prognosis (including Nutritional Status): Overall physical health: B Excellent Good Fair Poor List Mental (DSM) Diagnoses and Prognosis: Overall mental health: Excellent Good Fair Poor Focusing on the mental diagnoses most impacting functioning, describe relevant history: C. List all Medications: Name Do any of these medications impact mental functioning? Dosage/Schedule Yes No Uncertain If Yes, please identify which medications and how they impact mental functioning: American LegalNet, Inc. www.FormsWorkflow.com CJ-P 112 (3/08) D. Treatable, Reversible Causes and/or Mitigating Factors. Have temporary or reversible causes of mental impairment been evaluated and treated? Yes No Uncertain With time and treatment, mental functioning could: Improve Worsen Stay the same If the condition causing mental impairment is treatable or reversible, explain how functioning may improve. If there are mitigating factors such as hearing loss, vision loss, bereavement that may cause the person to appear incapacitated, describe these: weeks. If improvement is possible, the individual should be re-evaluated in 2. COGNITIVE AND EMOTIONAL FUNCTIONING A. Alertness/Level of Consciousness Overall Impairment: None Mild Moderate Severe Mild Moderate Non Responsive Severe Please describe: B. Memory and Cognitive Functioning Overall Impairment: None Please describe: C. Emotional and Psychiatric Functioning (e.g. mood, anxiety, psychotic, substance use, and other disorders) Overall Impairment: None Mild Moderate Severe Please describe: CJ-P 112 (3/08) American LegalNet, Inc. www.FormsWorkflow.com D. Fluctuation. Symptoms vary in frequency, severity, or duration: Yes No Uncertain 3. EVERYDAY FUNCTIONING. A. Activities of Daily Living (ADL'S) Ability to Care for Self (e.g. bathing, grooming, dressing, walking, toileting, etc.) Level of Function: Independent Needs Assistance/Support Needs Total Care Please describe: Is the individual willing to accept assistance? Yes No Uncertain Please explain: B. Instrumental Activities of Daily Living (IADL'S) Financial Decision-Making (e.g. bills, donations, investments, real estate, wills, protect assets, resist fraud, etc.) Level of Function: Independent Needs Assistance/Support Needs Total Care Please describe: Medical Decision-Making (e.g. ability to express a choice and understand and appreciate health information, etc.) Level of Function: Independent Needs Assistance/Support Needs Total Care Please describe: American LegalNet, Inc. www.FormsWorkflow.com CJ-P 112 (3/08) Care of Home and Functioning in Community (e.g. manage home, health, telephone, mail, drive, leisure, etc.) Level of Function: Independent Needs Assistance/Support Needs Total Care Please describe: Other Relevant Civil, Legal, or Safety Matters (e.g. sign documents, retain legal counsel, etc.) Level of Function: Independent Needs Assistance/Support Needs Total Care Please describe: 4. VALUES AND PREFERENCES. Please describe relevant values, preferences, and patterns. Note whether the person accepts/ opposes guardianship, goals for where/how life is lived, religious or cultural considerations. 5. RISK OF HARM TO SELF OR OTHERS A. Nature of Risks. Please describe the significant risks facing this person, and note whether these risks are due to this person's condition and/or due to another person harming or exploiting him or her. B. Social Network Relationships (Check one box in each category). Social Support Very good supportive network Some support from family and friends Limited or nonexistent support from family and friends. Social Skills Very good social skills Good social skills Poor social skills American LegalNet, Inc. www.FormsWorkflow.com CJ-P 112 (3/08) Please describe: C. How severe is risk of harm to self or others: D. How Likely is it: Almost Certain Mild Moderate Probable Possible Severe Unlikely 6. LEVEL OF CARE AND/OR SUPERVISION NEEDED, INCLUDING HOUSING Locked facility required 24 hr. supervision required Some supervision required No supervision required If a specific placement is being recommended, please describe: 7. THE INDIVIDUAL WOULD BENEFIT FROM: Education, training, or rehabilitation Yes No Uncertain Mental health treatment Yes No Uncertain Occupational, physical, or other therapy Yes No Uncertain Home and/or social services Yes No Uncertain Assistive devices or accommodations Yes No Uncertain Medical treatment, operation or procedure Yes No Uncertain Other: Yes No Uncertain Describe any specific recommendations: American LegalNet, Inc. www.FormsWorkflow.com CJ-P 112 (3/08) 8. ATTENDANCE AT HEARING The individual is able to attend the hearing at Court at the hospital or other facility or setting Please specify place and location: at his/her residence Accommodations, if any, required to facilitate participation: It is not in the best interests of the individual that she/he be required to attend the hearing for the following reason(s): 9. CERTIFICATIONS This form was completed based on: an examination for the purpose of capacity assessment of this individual my general clinical knowledge of this individual who is is not a patient under my continuing care and treatment. Prior to the examination, I informed the patient that communications would not be privileged: Yes No Other sources of information for this examination: Review of medical record Discussion with health care professionals involved in the individual's care Discussion with family or friends Other Names and titles of those individuals who assisted in preparation of this report: Name CJ-P 112 (3/08) Title American LegalNet, Inc. www.FormsWorkflow.com List any tests which bear upon the issue of incapacity and date of tests: Test (e.g. MMSE) Date I hereby certify that the evaluation of diagnosis, cognition, and function is within the scope of my professional competence based upon my education, training, and experience. I further certify that this report is complete and accurate to the best of my information and belief. Signed under the penalties of perjury: SIGNATURE OF CLINICIAN Date (Print name) License type, number, and date Office Address: (Street address) (City/Town) (State) (Zip) Office Phone: American LegalNet, Inc. www.FormsWorkflow.com CJ-P 112 (3/08)