Form MPC 400 at a glance
What it is: Medical Certificate for Guardianship or Conservatorship, of the Commonwealth of Massachusetts Trial Court, Probate and Family Court.
Notary: This document must be signed and dated by the person completing it. It does not need to be notarized.
The registered physician, licensed psychologist, certified psychiatric nurse clinical specialist or nurse practitioner completing this document must complete it. 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. If you receive information from others, the names of those individuals must be listed in the Certification Section and attribution identified.
A filled-in Form MPC 400 example: a physician certifies after an examination
How to fill out Form MPC 400, box by box
Which sections to complete
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 this individual in some or all areas of decision-making and functioning. If a guardianship or conservatorship is being sought for an intellectually disabled person, do not use this document; a separate Clinical Team Report is required.
All of the attached pages and sections contained therein must be completed.
If seeking guardianship of the person, complete section 3.1. If seeking only a conservatorship, do not complete this section.
If seeking conservatorship of the estate and affairs, complete section 3.2. If seeking only a guardianship of the person, do not complete this section.
Division, qualifications and the examination
Fill in the Docket No. and the Division.
The undersigned certifies under the penalties of perjury that I am: a registered physician specializing in the area of (write the area); a licensed psychologist; a certified psychiatric nurse clinical specialist; or a nurse practitioner with experience in the area of (write the area). Mark the line that applies.
Statement: I am prepared to present a statement of my qualification to the Court by written affidavit or personal appearance if directed to do so.
After I personally examined, write the Last Name, First Name and Middle Name, the (age), who resides at the address (Address Line 1, City/Town, State, Zip, Apt, Unit, No. etc.), and the Date(s) of Examination(s).
Prior to examination, I informed the patient that communications would not be confidential: mark Yes, or No, Explain.
1. Clinically diagnosed condition(s) that result in incapacity
Describe the individual's mental and physical conditions necessitating the appointment of a guardian and/or conservator, including the date of onset and disease course.
Under Stability of mental and physical condition and living setting, B: in the past 90 days, has the individual's mental and/or physical condition changed? Mark Yes, No or Uncertain; if yes, please explain.
In the past 90 days, has the individual's living setting (i.e. community, hospital, nursing facility) changed? Mark Yes, No or Uncertain, and if yes, please explain.
Prognosis for Improvement, C: with reasonable medical certainty, within the next 90 days, is the individual's mental and/or physical conditions likely to change substantially? Mark Yes, No or Uncertain; if yes, explain whether the condition is likely to worsen or improve.
If improvement is possible, the individual should be re-evaluated in weeks.
D. List all Medications (or attach list): Name, Dosage/Schedule. If an anti-psychotic medication indicate with a checkmark.
Could any of these medications impair mental functioning: Yes, No or Uncertain? If yes, explain.
2. Inability to receive and evaluate information or to make or communicate decisions
A, Alertness/Level of Consciousness: mark Overall Impairment as Non-Responsive, Severe, Moderate, Mild or None.
B, Memory and Cognitive Functioning: mark Overall Impairment as Severe, Moderate, Mild or None.
C, Emotional and Psychiatric Functioning: mark Overall Impairment as Severe, Moderate, Mild or None.
Describe how impairments in A, B, and/or C cause the individual to have an inability to receive and evaluate information or make or communicate decisions.
3.1 Guardianship: inability to meet essential requirements for physical health, safety, and self-care
Limited Guardianship is preferred by the Court; describe how the guardianship may be limited. Describe how the assessment was performed and give specific examples.
Areas in which the individual is able to meet the essential requirements for physical health, safety, and self-care: describe the individual's retained abilities and adaptive behavior for which the guardianship may be limited.
B. Areas in which the individual is unable to meet essential requirements for physical health, safety, or self-care: describe the impairments in physical health, safety, and self-care for which the individual requires a guardian.
If individual is unable to make any decisions for him or herself or is unable to meet any essential requirements for physical health, safety, and self-care (i.e. requires a full guardianship), describe why.
3.2 Conservatorship: inability to manage property or business affairs effectively
Limited Conservatorship is preferred by the court; describe how the conservatorship may be limited.
Areas in which the individual is able to manage property or business affairs effectively: describe the individual's retained abilities and adaptive behavior for management of property and estate for which the conservatorship may be limited.
Areas in which the individual is unable to manage property or business affairs effectively: describe the impairments in the management of property and business affairs for which the individual requires a conservator.
If the individual is unable to make any decisions about, and is unable to manage, any property or business affairs effectively (i.e. requires a full conservatorship), describe why.
4. Values and preferences
Describe the individual's values, preferences, and patterns, whether the individual accepts or opposes the guardianship/conservatorship, where the individual prefers to live, what makes life meaningful for the individual, and religious or cultural considerations.
6. Recommendations for level of care/supervision needed, including housing
A: an institutional placement being pursued at the following: Psychiatric facility, Other facility, Nursing home/Rehabilitation, None or Uncertain. If none, skip to section 7; if yes, answer:
B, the individual requires the following level of supervision: Locked facility, 24 hr. supervision, Some or None. Less restrictive placement options have been pursued: Yes, No or Uncertain. The placement is anticipated to be: Long-term, Short-term or Uncertain.
Describe the specific reasons for placement and efforts made to preserve the person's social support system (e.g. placement in community of residence or near family).
7. Recommendations for appropriate treatment and habilitation
The individual may benefit from the following; mark Yes, No or Uncertain for each: Educational potential, training, or rehabilitation; Technological assistance or accommodations; Mental health treatment; Occupational, physical, or other therapy; Home and/or social services; Medical treatment, operation or procedure.
Other: describe any specific recommendations.
8. Attendance at hearing
If it would be clinically harmful for the individual to attend the hearing, describe why.
If the individual is able to attend the court hearing, say what accommodations, if any, would enable the individual to attend the hearing.
9. Certifications
This form was completed based on an in-person clinical evaluation of the individual, who is or is not a patient under my continuing care and treatment.
In addition to a clinical examination, 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/relationships of those individuals who assisted in preparation of this report: write each Name and Title/Relationship.
List any tests which bear upon the issues of incapacity and date of tests: write each Test and Date.
Signed and dated
This document must be signed and dated by the person completing it. It does not need to be notarized.
By signing, you certify that the evaluation of diagnosis, cognition, and function is within the scope of your professional competence based upon your education, training, and experience. You further certify that this report is complete and accurate to the best of your information and belief. Signed under the penalties of perjury.
Date; SIGNATURE OF CLINICIAN; (Print name) License type, number, and date, Office Address: (Address) (City/Town) (State) (Zip) (Apt, Unit, No. etc.); Office Phone.
Sources
[1] MPC 400 (11/1/10), Medical Certificate, Guardianship or Conservatorship, Commonwealth of Massachusetts, Probate and Family Court (the Official source link on this page).
