Medical Certificate Guardianship or Conservatorship Form
page
of
MPC 400 (11/1/10) CRMDSEG
MEDICAL CERTIFICATE
GUARDIANSHIP OR
CONSERVATORSHIP
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
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, however, a guardianship or conservatorship is
being sought for an intellectually disabled person, do not use this
document. A separate Clinical Team Report is required.
INSTRUCTIONS FOR COMPLETION
To the registered physician, licensed psychologist, certified psychiatric nurse clinical specialist or a nurse
practitioner completing this document:
You must complete this document. 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. These persons might
include other healthcare professionals and/or others acquainted with the individual (e.g., family members or social service
professionals). If you receive information from others, the names of those individuals must be listed in the Certification
Section and attribution identified.
If you are completing this form on the computer and additional space is required for any narrative section, the
section will expand to permit additional information. Do not use medical terminology and/or abbreviations without
explaining them in terms that a lay person can understand.
ALL OF THE ATTACHED PAGES AND SECTIONS CONTAINED THEREIN MUST BE COMPLETED.
To the Honorable Justices of the Probate and Family Court:
The undersigned hereby certifies under the penalties of perjury that I am:
a nurse practitioner with experience in the area of:
a certified psychiatric nurse clinical specialist.
a licensed psychologist.
a registered physician specializing in the area of:
I am prepared to present a statement of my qualification to the Court by written affidavit or personal appearance if directed to
do so.
I personally examined:
Last Name
First Name
Middle Name
(Address Line 1)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
Date(s) of Examination(s)
who resides at
on
Prior to examination, I informed the patient that communications would not be confidential.
No, Explain:
Yes.
.
(age)
.
Division
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