Fillable GAL Application (Commonwealth of Massachusetts)

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GAL Application (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Page 1 of 4
JV-140 (Rev. 07/31/2018)
Mail Application to:
Administrative Office
of the Juvenile Court
1 Center Plaza, 7th Floor
Boston, MA 02108
APPLICATION
to the
Juvenile Court Department
for Appointment as Guardian Ad Litem
FOR COURT USE ONLY
_________________________
_________________________
_________________________
Initial Review
Approved
Entered
1) I have been appointed as an attorney (Atty), court investigator (CI), and/or a guardian ad litem (GAL) in
the following county division(s) of the Juvenile Court: (check all that apply)
All notices and announcements regarding the guardian ad litem fee-generating appointment list are sent by email.
2) Have you ever been removed from a fee-generating appointment list as an attorney, court investigator,
or guardian ad litem? No Yes If yes, please describe the circumstances for removal, indicate the
court(s) of removal and type of appointment(s) removed from.
Name:
Business Address:
Residential Address:
Telephone (Bus): Telephone (Res): FAX:
Email:
Barnstable
Atty
CI
GAL
Berkshire
Atty
CI
GAL
Bristol
Atty
CI
GAL
Essex
Atty
CI
GAL
Franklin/Hamp
Atty
CI
GAL
Hampden
Atty
CI
GAL
Middlesex
Atty
CI
GAL
Norfolk
Atty
CI
GAL
Plymouth
Atty
CI
GAL
Suffolk
Atty
CI
GAL
Worcester
Atty
CI
GAL
BBO No.:
Page 2 of 4
APPLICATION TO THE JUVENILE COURT DEPARTMENT
FOR APPOINTMENT AS GUARDIAN AD LITEM
3) Have you ever been investigated by the Department of Children and Families for allegations of child
abuse and/or neglect? No Yes If yes, describe the circumstances of the investigation.
4) I will accept appointments from the following county division(s) of the Juvenile Court Department:
(Please note: Appointments include all court locations within a county division.)
5) GUARDIAN AD LITEM CATEGORIES AND QUALIFICATIONS - Select and complete the guardian ad
litem category(ies) for which you are applying. Refer to Uniform Practice and Procedure Regarding the
Appointment of Guardians Ad Litem Juvenile Court Department 01-2015 for a complete description
of each category.
Guardian Ad Litem - Extraordinary Medical Treatment qualifications: An attorney who is a member in good
standing of the Massachusetts Bar with five (5) years experience in child welfare protective cases or five (5) years
experience representing adults in extraordinary medical care matters.
I certify that:
I am an attorney and member in good standing of the Massachusetts Bar
with,
Check all that apply:
five (5) years experience in child welfare protective cases.
five (5) years experience representing adults in extraordinary medical care matters.
Name:
Barnstable Berkshire Bristol Essex Franklin/Hamp Hampden
Middlesex Norfolk Plymouth Suffolk Worcester
Page 3 of 4
APPLICATION TO THE JUVENILE COURT DEPARTMENT
FOR APPONTMENT AS GUARDIAN AD LITEM
Guardian Ad Litem - Treatment Monitor qualifications: An attorney who is a member in good standing of
the Massachusetts Bar with three (3) years experience in child welfare protective cases or with three (3) years
experience representing adults in extraordinary medical care matters.
I certify that:
I am an attorney and member in good standing of the Massachusetts Bar
with,
Check all that apply:
three (3) years experience in child welfare protective cases.
three (3) years experience representing adults in extraordinary medical care matters.
Guardian Ad Litem - Education Surrogate qualifications: An individual who is not employed by an agency
involved in the care or education of his/her assigned student, who does not have personal or professional interests
that conflict with the assigned student's interest and who has or is willing to obtain adequate knowledge in special
education and IEP process or an attorney who is a member in good standing of the Massachusetts Bar with three
(3) years experience representing the interest of children in education matters.
I certify that (check all that apply):
I have or I am willing to obtain adequate knowledge in special education and IEP process.
I am an attorney and member in good standing of the Massachusetts Bar with three (3) years experience
representing the interests of children in educational matters.
Guardian Ad Litem - Legal Rights/Privilege
and/or
Guardian Ad Litem - Legal Rights/Claims
Qualifications: An attorney who is a member in good standing of the Massachusetts Bar with three (3) years
experience in child welfare protective cases.
I certify that:
I am an attorney and member in good standing of the Massachusetts Bar with three (3) years experience in
child welfare protective cases.
Guardian Ad Litem - Legal Rights/Advisor qualifications: An attorney who is a member in good standing
of the Massachusetts Bar with three (3) years experience in child welfare protective cases or with three (3) years
experience in delinquency and/or youthful offender cases.
I certify that:
I am an attorney and member in good standing of the Massachusetts Bar
with,
Check all that apply:
three (3) years experience in child welfare protective cases.
three (3) years experience in delinquency and/or youthful offender cases.
Name:
Page 4 of 4
APPLICATION TO THE JUVENILE COURT DEPARTMENT
FOR APPOINTMENT AS GUARDIAN AD LITEM
Guardian Ad Litem - Evaluator qualifications: An individual with a Masters degree or higher degree who
holds a Massachusetts license in social work, counseling psychology or clinical psychology or who is a registered
nurse with at least three (3) years experience in child welfare protective cases, or an attorney who is a member in
good standing of the Massachusetts Bar with at least five (5) years experience in child welfare protective cases.
I certify that
(check all that apply):
I have a Masters degree or higher degree and hold a license in:
social work clinical psychology
counseling psychology
I am a registered nurse with at least three (3) years experience in child welfare protective cases.
I am an attorney and member in good standing of the Massachusetts Bar with at least five (5) years experience
in child welfare protective cases.
FOR OFFICE USE ONLY
Guardian Ad Litem - Diminished Capacity qualifications: An individual with a Masters degree or highter
degree who holds a Massachusetts license in social work, counseling psychology or clinical psychology.
I certify that
(check all that apply):
I have a Masters degree or higher degree and hold a license in:
social work clinical psychology
counseling psychology
If I am approved to accept appointments, I understand that I am required to participate in six (6) hours of continuing
education per year. I understand that if I have not mailed the necessary certificate of completion of continuing legal,
clinical, or other education program approved by the Administrative Office of the Juvenile Court (AOJC) by June
30th of each year, that I will be ineligible to accept appointments. The following documents are attached to my
application:
1) Letter of interest addressing my qualifications,
2) Current resume, including relevant educational training or classes in which I participated as an attendee
or instructor,
3) Three references including contact information, and
4) Notarized Consent to Criminal Offender Record Information Check (AOJC form JV-083).
I understand that the Administrative Office of the Juvenile Court will not process my application unless I provide all
of the above listed documents.
I certify under the penalties of perjury that all of the above information is true and complete.
Date: _________________________ Signature: __________________________________________________
Name:
License No.
License No.
License No.
License No.
License No. License No.
License No.
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GAL Application (Commonwealth of Massachusetts)

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Completed 26 July 2020

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