Form Jv-140 - Application To The Juvenile Court Department For Appointment As Guardian Ad Item Page 4
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4APPLICATION TO THE JUVENILE COURT DEPARTMENT
FOR APPOINTMENT AS GUARDIAN AD LITEM
Name:
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:
License No.
License No.
social work
clinical psychology
License No.
counseling psychology
I am a registered nurse with at least three (3) years experience in child welfare protective cases.
License No.
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.
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:
License No.
License No.
social work
clinical psychology
License No.
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: __________________________________________________
FOR OFFICE USE ONLY
Page 4 of 4
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