Form Mpc 800 - Clinician'S Affidavit As To Competency And Treatment
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5Commonwealth of Massachusetts
Docket No.
CLINICIAN'S AFFIDAVIT AS TO
The Trial Court
Probate and Family Court
COMPETENCY AND TREATMENT
In Re: Guardianship of:
Division
First Name
Middle Name
Last Name
Proposed Incapacitated Person/Respondent
I,
, do hereby state to my best knowledge and belief:
Last Name
First Name
M.I.
1. I am a licensed physician, certified psychiatric nurse clinical specialist, or other person so authorized by law to prescribe
antipsychotic medication in Massachusetts. I am employed by
.
2. I supervise the psychiatric treatment of Respondent who is a
resident
patient
at
(Apt, Unit, No. etc.)
(Name of Facility)
(Address)
.
(City/Town)
(State)
The Respondent is a
year old
male
female
who was admitted on
.
3. I first consulted on the treatment of the Respondent on
. On that date, and since that
time, I observed the Respondent and reviewed the Respondent's medical records. I am familiar with the Respondent's
case history.
4.
I have conferred with the following clinical staff in rendering the opinions expressed in this affidavit:
Name
Title/Relationship
5. Respondent's clinically diagnosed condition is:
6. The Respondent was admitted or most recently treated under the following circumstances:
7. Respondent has had this condition for
days
weeks
months
years
other:
.
In the past the condition has been
untreated
treated as follows:
MPC 800 (6/17/11)
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