Fillable Mpc404 Report Of Monitor Fill (Commonwealth of Massachusetts)

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Mpc404 Report Of Monitor Fill (Commonwealth of Massachusetts)

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MPC 404 (8/30/19) RPTM
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REPORT OF MONITOR
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
In the Interests of:
Last Name
First Name
Middle Name
Incapacitated Person
Division
1.
The Monitor of the Treatment Plan for the Incapacitated Person is:
First Name
M.I. Last Name
(Address)
(Apt, Unit, No. etc.) (City/Town)
(State) (Zip)
Primary Phone #:
The Monitor was appointed on is notis the Guardian.
Relationship to Incapacitated Person
(date)
the Conservator.is notis
and
The Monitor
The Incapacitated Person currently lives at2.
(Address)
(City/Town)
(State) (Zip)(Apt, Unit, No. etc.)
which is a
Community Residence DDS-operated Regional Center DMH Facility Nursing Facility Private Home
Other:
3. The Monitor last met with the Incapacitated Person on
(date)
The following was specifically discussed with the Incapacitated Person:
.
The Monitor reviewed the Incapacitated Person's medical records, the Treatment Plan that was allowed by this Court on
(date)
4.
The Incapacitated Person's treatment with antipsychotic medications
in compliance with the current
is is not
If the treatment is not in compliance with the current Court Order, please explain the non-compliance:
(date)
Court Order.
and other relevant information, on
MPC 404 (8/30/19) RPTM
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The Incapacitated Person is currently receiving the following antipsychotic medications:5.
ANTIPSYCHOTIC MEDICATION: DOSAGE:
The Monitor is in agreement with the clinician's opinion that the Incapacitated Person continues to be unable to make
medical treatment decisions, and continues to need a court order for antipsychotic medication. The conditions and
circumstances that necessitated the Court's present Order do not appear to have changed substantially.
6.
The Monitor has discussed the Incapacitated Person's present status and treatment needs with the treating clinician.
7.
No. Explain on what date efforts were made to contact the clinician, in detail, and whether the clinician's progress
Yes. Specify what was discussed, whether in person or by telephone, and when.
notes were reviewed.
The Monitor has spoken with the Incapacitated Person's Residential and/or Day program staff, if any, and with other
treatment providers regarding the Incapacitated Person's present status and current treatment needs. Specifically, we
have discussed the following (indicate with whom, whether in person or by telephone, and on what dates):
8.
I certify that a signed copy of this Report was provided to each of the following persons at least thirty (30) days prior to the
expiration of the current Treatment Plan:
Name Relationship Address Manner* Date
Counsel for the
Incapacitated Person
Moving Party
* Indicate if by hand delivery, first class mail, certified mail, or if by agreement, by e-mail or facsimile.
MPC 404 (8/30/19) RPTM
ofpage
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.
Signature of Monitor
Date
Signature of Co-Monitor (if applicable)
Date
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Mpc404 Report Of Monitor Fill (Commonwealth of Massachusetts)

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Completed 27 July 2020

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