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Get MA MPC 821 2019-2024

The Guardian s Care Plan/Report was acknowledged on MPC 821 5/30/11 RPTA RPT60 Date. page of CONDITIONS AND SERVICES 2. GUARDIAN S CARE PLAN/REPORT Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No* Division In the Interests of Middle Name First Name Last Name Incapacitated Person INSTRUCTIONS TO GUARDIAN Fill this Report out completely then sign and date on the last page. Attach separate sheets if needed to complete your response to the numbered questions. File original Report with the Court and serve the Incapacitated Person in hand or by certified mail return receipt requested* Complete the Certificate of Service at the end of this Report. Age of Incapacitated Person Check one box INITIAL 60 DAY CARE PLAN Your relationship to Incapacitated Person ANNUAL REPORT OTHER Current Reporting Period From date to CURRENT CONDITION OF THE INCAPACITATED PERSON 1. Describe the Incapacitated Person s mental physical and social condition* LIVING ARRANGEMENTS 1a* List the name type of facility and address of each place where the Person currently resides and where the person stayed or resided during the reporting period and include the dates each stay or residence began and ended* Dates of Stay or Residency Address If facility list name and type of facility and answer Q1b. below click to remove click to add 1b. Please explain whether you consider the current living arrangements or habilitation plan and level of care and treatment to be in the Incapacitated Person s best interest. SERVICES PROVIDED TO THE INCAPACITATED PERSON Describe the medical educational vocational and other services provided to the Incapacitated Person during the reporting period. Do you believe that the current care and services are adequate to meet the Person s needs Yes No Please explain your opinion about the adequacy of care and services. 3. ANTIPSYCHOTIC MEDICATION Is the Incapacitated Person taking and/or receiving antipsychotic medication s If Yes and you are also the Court appointed Rogers Monitor you may attach a Rogers Monitor Supplemental Report in lieu of a Roger s Monitor Report. 4. PROTECTION OF INCAPACITATED PERSON Have any criminal charges or reports of abuse or neglect involving the Incapacitated Person been filed with a court or agency since the last report If Yes please explain 5. GUARDIAN S VISITS AND CONTACT WITH CAREGIVERS Describe the nature and frequency of your visits with the Incapacitated Person your contact with caregivers and health care providers and any other activities you undertook on the Incapacitated Person s behalf during the reporting period. 6. INCAPACITATED PERSON S PARTICIPATION IN DECISION-MAKING Describe the extent to which the Incapacitated Person did/did not participate in decision-making about personal and health care decisions. 7. LEVEL OF CARE The Incapacitated Person s care is very good good adequate poor FUTURE CARE 8. RECOMMENDED CHANGES guardianship or the Incapacitated Person s future care. 9. FUTURE ARRANGEMENTS Describe what residence services and levels of personal/health care you expect to arrange for the Incapacitated Person during the next 18 months.

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