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Applicationcathrogersmonitor

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FOR COURT USE ONLY
Initial Review
Approved
Entered
APPLICATION to the
Probate and Family Court Department
for Appointment
Category H
ROGERS MONITOR
ROGERS and geriatric ROGERS cases
G. L. c. 190B §5-306A(b)
Mail Application to:
Probate and Family Court
Administrative Office
John Adams Courthouse
One Pemberton Square
Mezzanine
Boston, MA 02108
JULY 2017 CATEGORY H- ROGERS MONITOR
ofpage
Name:
Firm/Organization Name:
Address:
Telephone Number: E-Mail Address:
B.O.R. Number:
Proficient in the following languages:
Special experience/expertise (optional):
Website:
I am
A.
an attorney licensed to practice before the Supreme Judicial Court on
(date)
and have at
least three years of related professional experience since licensure in Massachusetts. I certify that I remain in good
standing to practice before the courts of the Commonwealth of Massachusetts, and that I have not been convicted of
any felony.
B.
with at least three years of related professional experience since licensure in Massachusetts.
I certify that I have been licensed since
(date)
,that I remain in good standing with said Board
of Registration, and that I have not been convicted of any felony.
I currently have professional liability insurance coverage of $100,000 or more. A copy of the insurance binder indicating the
date and amount of coverage is included with this application.
a person with an advanced degree in medicine psychology social work
I request and will accept appointments from the following (maximum of four) divisions of the Probate and Family Court
Department:
Barnstable
Hampshire NorfolkNantucket
Dukes Bristol
Middlesex
Berkshire Essex
Plymouth
Franklin
WorcesterSuffolk
Hampden
WITH THIS APPLICATION, I AM SUBMITTING THE FOLLOWING:
a copy of my resumé or curriculum vita;
a copy of my insurance binder;
a certificate of good standing, dated within the past 30 days, from the Board of Registration that issues my license.
I am currently on the Category A fee-generating appointment list.
JULY 2017 CATEGORY H- ROGERS MONITOR
ofpage
If this application is APPROVED, I understand that:
1. When I am appointed by the Court, I may not delegate any aspect of that appointment to anyone else.
2.
If I am appointed as ROGERS Monitor and a person with an appearance in the case requests a certificate of my
professional liability insurance, I will provide the certificate within seven (7) days of such request.
3.
To remain on this list for appointments, I understand that I am required to attend, on an annual basis, a minimum of six (6)
hours of continuing education approved by the Administrative Office of the Probate and Family Court.
4.
I will receive payment as a ROGERS Monitor from the Commonwealth, for up to ten(10) hours per calendar year without
prior judicial approval. SEE Rogers v Commissioner of the Department of Mental Health, 390 Mass. 489 (1983). Any
excess over ten(10) hours per calendar year must be approved by a judge. A motion accompanied by a supporting affidavit
which indicated special circumstances regarding the administration of antipsychotic medication which warrants the need for
additional hours must be presented.
I agree that the Administrative Office may access a CARI (Criminal Activity Record Information) report. I understand that
this is required as a condition of my inclusion on the fee generating appointment list and, that the report will be kept
confidential at the Probate and Family Court Administrative Office.
SIGNED UNDER THE PENALTIES OF PERJURY
I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.
Date:
Signature
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Completed 2 January 2020

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