Fillable Mpc402 Clinical Team Report Fill (Commonwealth of Massachusetts)

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Mpc402 Clinical Team Report Fill (Commonwealth of Massachusetts)

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MPC 402 (5/30/11)
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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 an individual with an intellectual disability. A
licensed psychologist, registered physician, and licensed social worker,
each of whom is experienced in the evaluation of persons with an
intellectual disability, must complete this form.
CLINICAL TEAM REPORT
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
INSTRUCTIONS FOR COMPLETION
Docket No.
Division
(Zip)
To the Honorable Justices of the Probate and Family Court:
First Name
Last Name
Middle Name
(Address)
(City/Town)
(State)
(Apt, Unit, No. etc.)
Date(s) of Examination(s)
who resides at
Area of specialty
Date(s) of Examination(s)
Dates of Examination(s):
Registered physician specializing in
on
Date(s) of Examination(s)
Licensed social worker on:
Licensed psychologist on:
are licensed by the Commonwealth of Massachusetts and are experienced in evaluation of persons with an intellectual
disability;
personally examined
1.
2.
Age
Yes
No
Explain:
CERTIFICATION OF METHODS OF EVALUATION
This form was completed based on an in-person clinical evaluation of the individual.
In addition to a clinical examination, other sources of information for this examination:
Review of intellectual, adaptive and other relevant evaluations;
Discussion with professionals involved in the individual's care;
Discussion with family or friends;
1.
MPC 402 (5/30/11)
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Other.
Names and titles/relationships of those individuals who assisted in preparation of this report:
Name
Title/Relationship to individual
List any intellectual, adaptive or other evaluations reviewed and dates of tests.
Test
Date
State numerical result for IQ test.
Diagnosis of Intellectual Disability
Does the individual have an Intellectual Disability which is defined in G.L. c. 190B, §5-101(12) as a substantial
limitation in present functioning beginning before age 18, manifested by significantly sub average intellectual
functioning existing concurrently with related limitations in two or more of the following applicable skills area:
communication, self-care, home living, social skills, community use, self-direction, health and safety, functioning
academics, leisure and work.
No
Yes
CLINICALLY DIAGNOSED CONDITION(S) THAT MAY RESULT IN INCAPACITY
A.
Intellectual Disability
2.
List diagnosis and describe level of Intellectual Disability and impact on capacity to make informed decisions.
B.
Other Relevant Diagnoses: (List other relevant physical or mental diagnoses that affect decision making ability.)
C.
List all Medications that may influence ability to make informed decisions:
Name of medication/dosage/schedule
Describe any positive or negative influence of each medication
on the individual's ability to make informed decisions
D.
Factors believed to impede current capacity for decision-making.
Are there any factors that could make the individual appear confused but which could improve with time or treatment,
such as delirium, acute medical illness, the interaction of multiple medications, hearing loss, vision loss, bereavement,
etc.? If so, describe these factors and explain how functioning might improve:
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MPC 402 (5/30/11)
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INTRUSIVE TREATMENTS PRESCRIBED/PROPOSED
A.
Antipsychotic Medications
Check if the individual is prescribed any antipsychotic medications that may require a Rogers treatment plan.
In your opinion is the individual capable of giving informed consent to treatment with antipsychotic medication?
Yes
No
Explain:
3.
B.
Other Intrusive Interventions
Check if other intrusive interventions and/or any extraordinary medical treatments are being proposed at this time,
such as electroconvulsive therapy, Level III behavioral treatment plan, sterilization, amputation(s), removal of
organ(s) and organ transplant(s).
If checked, describe the procedure or intervention being proposed:
In your opinion is the individual capable of giving informed consent to the proposed intervention?
Yes
No
Explain:
SOCIAL NETWORKS TO ASSIST IN DECISION MAKING
Does the individual have a social network that he or she utilizes to assist in decision making?
Explain:
Yes
No
4.
RISK OF HARM TO SELF OR OTHERS
A.
Nature of Risks. Describe any significant risks of physical or emotional harm to or exploitation of the individual:
5.
B.
How severe is risk of harm?
Mild
Substantial
Life Threatening
C.
How likely is risk of harm or exploitation?
Almost Certain
Probable
Possible
Unlikely
MPC 402 (5/30/11)
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RECOMMENDATION ON GUARDIANSHIP/CONSERVATORSHIP
6.
GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR HEALTH, SAFETY, AND SELF CARE
6.1
Areas in which the individual is able to make informed decisions with respect to his or her adaptive skill areas
including physical health, safety, and self-care:
A.
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).
Areas in which the individual is unable to make informed decisions with respect to his or her adaptive skill areas
including physical health, safety, or self-care:
Describe the impairments in physical health, safety, and self-care for which the individual requires a Guardian.
B.
If individual is unable to make any decisions for him or herself or is unable to make informed decisions with
respect to physical health, safety, and self care (i.e. requires a full guardianship), describe why:
C.
CONSERVATORSHIP: INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY
If seeking a full or limited conservatorship of the person, complete section 6.2. Limited Conservatorship is
preferred by the court.
A.
Areas in which the individual is able to manage property or business affairs effectively:
What abilities can the individual retain in management of his or her property and estate (e.g., ability to manage
allowance, bills, donations, investments, real estate, protect assets, resist fraud)?
6.2
B.
Areas in which the individual is unable to manage property or business affairs effectively:
What are the impairments in the management of property and business affairs for which the individual requires a
conservator? Describe how the person has property that will be wasted or dissipated unless management is provided
or describe how protection is necessary to provide money for the support, care and welfare of the person or those
entitled to the person's support.
C.
If the individual is unable to make any decisions about, and is unable to manage, any property or business
affairs effectively (i.e. requires full conservatorship), describe why:
MPC 402 (5/30/11)
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The individual is able to attend the court hearing.
ATTENDANCE AT HEARING
Yes
No
Is it likely that it would be clinically or emotionally harmful for the individual to attend the court hearing?
Yes
No
7.
Explain:
Describe the accommodations, if any, that are required to facilitate the individual's participation in the court
hearing:
SIGNATURES OF CLINICIANS WHO COMPLETED THIS FORM
This document must be signed and dated by the 3 persons completing it. It does not need to be notarized. *
I hereby certify that the evaluation of this individual 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.
8.
(SIGNATURE OF LICENSED PSYCHOLOGIST)
(Print name)
Date:
(License type, number and date)
(Address)
(City/Town)
(State)
(Zip)
Office Phone #:
(Apt, Unit, No. etc.)
(SIGNATURE OF REGISTERED PHYSICIAN)
(Print name)
Date:
(License type, number and date)
Office Phone #:
(Address)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
(SIGNATURE OF LICENSED SOCIAL WORKER)
(Print name)
Date:
(License type, number and date)
Office Phone #:
(Address)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
* All Signatures must be originals but all signatures need not be on the same page.
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Mpc402 Clinical Team Report Fill (Commonwealth of Massachusetts)

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Completed 26 July 2020

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