CD, Section I: Court Appointments
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SECTION
I
Court Appointments
This section contains a number of different court orders. First, I have included
several orders appointing a child custody evaluator to illustrate some of the variations,
which include:

Degree of detail in definition of scope of evaluation

Specific statement authorizing the custody evaluator to have access to medical,
hospital, school, psychological, and agency records.
o Even when such an authorization is included in the court order, it is still
wise for evaluators to obtain a signed Authorization for Release of
Information form for each person they wish to contact because much of
this information is privileged.

Date when report is due.

Provisions for payment by private parties or by the state, and in what proportions.

Contact information for attorneys, or for parties pro se (representing themselves)

Instructions for the custody evaluator to sign the form before a notary public to
accept the appointment, and return the signed form to the appointing court.
Some court appointment forms for child custody evaluators are available on-line,
including:

Order for full or partial child custody evaluation -Superior Court of California, County of Solano.
Available at http://www.slocourts.net/civil/docs/fl009.pdf

Stipulation and court order for partial child custody evaluation—
Superior Court of California, County of Solano.
Available at http://www.solanocourts.com/pdf/forms/family/SL-303.PDF
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Next, I have included a sample of a court order appointing a Guardian to determine
whether the minor child’s psychotherapist and/or social worker privilege should be
exercised or waived.
The specific court orders included in Section I of this CD are:

Short Appointment Form with Checklist of Issues -- #1

Short Appointment Form with Checklist of Issues -- #2

Detailed Appointment Form with Checklist of Issues -- #1

Detailed Appointment Form with Checklist of Issues -- #2

Appointment Form with Blank Lines for Judge to Define Issues

Narrative Appointment Form -- #1

Narrative Appointment Form -- #2

Appointment Form Regarding Child/Psychotherapist Privilege
To use these court orders, simply replace the existing identifying information with the
correct information regarding the court or jurisdiction, the judge issuing the order, the
came name and docket number, and so on. In some cases, minor differences in
language are required to make the court order conform to local usage (such as referring
to the appointment of a child custody evaluator rather than a Guardian Ad Litem). Of
course you will also need to remove the footnotes, which are included here to provide
reprint permission and/or more detailed information about the court order.
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SHORT APPOINTMENT FORM WITH CHECKLIST OF ISSUES -- #1
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court Department
Middlesex, ss1
Docket
No.______________
ORDER APPOINTING A GUARDIAN AD LITEM OR PROBATION OFFICER
___________________________________________________________________ , Plaintiff
v.
__________________________________________________________________, Defendant
FROM LIST:2
○ Yes
SUCCESSIVE: ○ Yes
○ No
○ No
○ not applicable, probation
○ not applicable, candidate
selected by agreement of
parties
○ not applicable, probation
○ not applicable, candidate
selected by agreement of
parties
Whereas custody and/or visitation with child(ren) is an issue in this matter, it requires the
appointment of a:
○
PROBATION OFFICER, to be designated by the Probation Department
○
GUARDIAN AD LITEM______________________________________________________
Address:________________________________________Telephone:______________
To act as:3
○ guardian ad litem/next friend for such person(s) to represent his/her/their interests in
said case
○ guardian ad litem/investigator to investigate and report on the issues below
○ guardian ad litem/evaluator to evaluate and report on the issues listed below
○ guardian ad litem/next friend to determine whether the patient-psychotherapist and/or
social worker-client privilege of such person should be exercised or waived.
The guardian ad litem or probation officer named above shall investigate, evaluate and report to
the court on:
○ issues of legal and physical custody
○ need for supervised visitation
○ issues of visitation/parenting plan/access to child(ren)
○ removal of children from the state
○ the relationship between the children) and the custodial parent and/or non-custodial
parent.
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○ other_______________________________________________________________
A report shall be filed with the PROBATION DEPARTMENT on or before:
The guardian ad litem shall be paid by:
○ _______________________________________
○ the Commonwealth of Massachusetts.
______ hours are authorized with leave to
request more by motion, if necessary.
Date:____________________________
__________________________________________________
[Printed name of judge]
Justice of the Probate and Family Court
Plaintiff’s Attorney or Plaintiff, if pro se
Defendant’s Attorney or Defendant, if pro se
Name:
Name:
Address:
Address:
Telephone:
Telephone:
INSTRUCTIONS; PLEASE SIGN THE REVERSE SIDE OF THIS ORDER BEFORE A NOTARY
PUBLIC TO ACCEPT THIS APPOINTMENT AND RETURN THIS ORDER TO THE COURT.
_____________________________________
This is the standard GAL appointment form used by the Middlesex division of the Massachusetts Probate
and Family Court. Unlike other jurisdictions, in Massachusetts child custody evaluators are appointed as
Guardians Ad Litem.
2 Massachusetts requires that potential GALs be registered. To avoid favoritism among GALs, judges are
supposed to make appointments to the next available GAL on the list, unless particular expertise is
required due to special issues in a given case (e.g., sexual abuse of child, substance abuse, domestic
violence). The parties and their attorneys may also choose a GAL before the court hearing; appointment
of such pre-chosen GALs does not require the use of the GAL list.
3 Massachusetts distinguishes between guardian ad litem/investigator and guardian ad litem/evaluator.
GAL/investigator appointments are made from the GAL F list, comprised of attorneys and mental health
professionals; these appointments are primarily for factual investigation. (See Comm. Mass., 2005b for
Standards for category F guardian ad litem investigators.) GAL/evaluator appointments are made from
the GAL E list, comprised only of mental health professionals; these appointments are for evaluations that
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require the expertise of an experienced forensic mental health professional. (Standards for Category E
evaluators are currently being developed.)
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SHORT APPOINTMENT FORM WITH CHECKLIST OF ISSUES -- #2
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court Department
______________ Division
Docket No.__________
___________________________________________________, Plaintiff
vs.
___________________________________________________, Defendant
ORDER APPOINTING A GUARDIAN AD LITEM
FOR MINOR CHILD(REN) IN CUSTODY/VISITATION MATTERS
After hearing, it appears that the best interests of the minor child(ren) require the appointment of
a guardian ad litem.
The Court appoints ___________________________________________________to serve in
the capacity of guardian ad litem.
The Court orders the guardian ad litem to investigate and report back to the Court regarding:
○ issues of legal and physical custody.
○ issues of visitation /parenting plan / access to children.
○ allegations of ______________________________________________________________
○ the relationship between the minor child(ren) and the custodial and/or non-custodial parent.
○ removal of the child(ren) from the Commonwealth
○ Other (please describe):_______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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The guardian ad litem shall have access to agency, medical, hospital, school and psychological
records, excluding those records which are privileged.
The guardian ad litem is to be contacted by attorneys for the parties, or by the parties
themselves if they are unrepresented by counsel. The guardian ad litem shall be provided with
whatever information is necessary for him/her to carry out his/her functions.
A report shall be filed within ______________________________________________________
Date________________
_______________________________________
Justice of the Probate and Family Court
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DETAILED APPOINTMENT FORM WITH CHECKLIST OF ISSUES -- #14
STATE OF ________________________________
The Trial Court
Probate and Family Court
_______________Division.
Docket No. _____________
___________________________, Plaintiff vs. _____________________________, Defendant
or
In Re: Guardianship of _____________________________________________
ORDER APPOINTING A GUARDIAN AD LITEM
IN CUSTODY/VISITATION/GUARDIANSHIP MATTERS
After hearing on _______________ with respect to the __________________________
filed on _______________, it appears that the best interests of the minor child(ren) of this
matter:
__born _____________________
____________________________________________ born _____________________
____________________________________________ born _____________________
require the appointment of a Guardian ad Litem (hereinafter “GAL”).
Therefore, this Court hereby appoints________________________________________,
____________________________________________________________________________
to serve as GAL/Investigator.
The Court orders the GAL to investigate and report back to the Court regarding:
□ I. issues of legal and physical custody
□ II. visitation/parenting plan/access to the child(ren)
allegations of ___________________________________________________
□ III. the need for supervised visitation
□ IV. the relationship between the minor child(ren) and the custodial and/or noncustodial parent
4
This appointment form was developed by Hon. Geoffrey A. Wilson, Massachusetts Probate and Family
Court. The original terms have been retained, and would need to be altered for many jurisdictions. For
instance, in Massachusetts custody evaluators are appointed as “Guardians Ad Litem,” whereas in other
jurisdictions the term “custody evaluator” is used. This appointment form is reprinted with the permission
of Judge Wilson.
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□ V. the relationship between the child(ren) and the proposed guardian
□ VI. whether the proposed guardian is suitable and understands the responsibilities of
a guardian
□ VII. removal of the child(ren) from the Commonwealth of Massachusetts
□ VIII. facts and circumstances related to the present fitness of the parent(s)
□ IX. and other issues as the investigator may deem necessary
The GAL shall have access to agency, medical, hospital, school and psychological records,
excluding those which are privileged; prior GAL reports, if any; and access to the parties’
criminal records (CORI/CARI).
The parties or their attorneys shall contact the GAL and provide any information requested to
assist the GAL with the performance of his or her duties.
The GAL shall file a written report with the Court, in a form which complies with the Standards
for Category F, Guardians ad Litem/Investigators in Actions Involving: Domestic
Relations or Custody/Visitation/Adoption; G.L. c.215 §56A; c.208, §16, Effective:
January 24, 2005, on or before ___________________________________________ . 5
(see next page)
The report shall include, in separate sections, the GAL’s inferences and/or conclusions, and his
or her recommendations, if any, based only upon the facts set forth in the body of the report.
The fee for services of the GAL shall not, without prior Court approval, exceed:
$600 (paid by the Commonwealth) or $1500 (paid by the parties), and shall be paid
I. __________initially by the Commonwealth of Massachusetts, subject to possible
recoupment from the parties from the parties at a later date.
II. __________% by the Plaintiff
III.__________% by the Defendant
IV. _________arrangements for private payment shall be made directly between the
parties and the GAL . The GAL may elect not to begin the investigation until receipt
of a deposit toward the fee.
A _____________________ is scheduled for ____________________ at ____________; a
separate ___________________________________ shall issue with respect thereto.
Date: ___________________________
Justice, Probate and Family Court
5
See footnote 3 above, which explains Mass. Regulations regarding categories of GALs and the
applicable standards.
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NOTE: All Guardians and Guardians ad Litem must comply with Supreme Judicial
Court Rule 1:07.6
***************
I, _____________________________________________, hereby accept the above
appointment and acknowledge receipt of Fiscal Year 1997 Memo #14. I also acknowledge
familiarity with the standards for Category F, Guardian ad Litem/Investigators in Actions
Involving: Domestic Relations or Custody/Visitation/Adoption; G.L. c.215 §56A; c.208, §16,
Effective: January 24, 2005.
Date: _________________________
_______________________________________
(signature of person appointed)
*****************
Franklin, ss.
Personally appeared before me the above-named
_____________________________________ and made oath that he would faithfully and
impartially perform the duty imposed on him by the foregoing appointment.
Date: ______________
Register /Judicial Case Manager
****************
I have completed my investigation and have filed a written report as ordered.
Date: _________________________
_________________________________________
(signature of person appointed)
6
Massachusetts Supreme Judicial Court Rule 1:07 concerns requirements for record-keeping and
reporting. It states that, “No payment shall be make or received on account of any appointment required
to be recorded in the appointment docket until a statement under the penalties of perjury, certifying the
services provided, amount of payment, and itemization of expenses, is filed with the clerk, register, or
recorder, to be placed with the papers in the case. No person holding an appointment required to be
recorded in the appointment docket under Section (5) of this rule shall make any payment to himself or
herself until such payment is approved by the court.”
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DETAILED APPOINTMENT FORM WITH CHECKLIST OF ISSUES -- #27
COMMONWEALTH OF MASSACHUSETTS
The Trial Court
Probate and Family Court
Hampshire, ss.
Docket No.
, Plaintiff
vs.
, Defendant
ORDER APPOINTING A GUARDIAN AD LITEM
IN CUSTODY/VISITATION MATTERS
After hearing on _______________ on the _________ filed ____________, it appears
that the best interests of the minor child(ren) of this matter:
__born _____________________,
____________________________________________ born _____________________,
____________________________________________ born _____________________,
require the appointment of a Guardian ad Litem.
1. APPOINTMENT. This Court hereby appoints______________________________ of,
__________________________to serve as (Guardian Ad Litem/_____________) (Clinical
Guardian Ad LItem).
2. SCOPE OF INVESTIGATION.
the Court regarding:
□
□
□
7
The Guardian Ad Litem shall investigate and report back to
Issues of legal and physical custody
Issues of visitation/parenting plan/access to the child(ren)
Allegations of ___________________________________________________
This appointment form was developed by Hon. Gail L. Perlman, Massachusetts Probate and Family
Court. The original terms have been retained, and would need to be altered for many jurisdictions. For
instance, in Massachusetts custody evaluators are appointed as “Guardians Ad Litem,” whereas in other
jurisdictions the term “custody evaluator” is used. This appointment form is reprinted with the permission
of Judge Perlman.
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□ Need for supervised visitation
□ The relationship between the minor child(ren) and the custodial and/or non-custodial parent.
□ Removal of the child(ren) (from the Commonwealth) (from their current location)
□ Other____________________________________________________________________
and such other issues as the Guardian Ad Litem may deem necessary.
3. GUARDIAN AD LITEM’S ACCESS TO INFORMATION.
A. Information from Parties.
The parties or their attorneys shall contact the Guardian Ad Litem and provide any
information requested to assist the Guardian Ad Litem with the performance of his or her
duties.
B. Information from Third Parties
The Guardian Ad Litem shall have the right to read and receive copies of records of
governmental agencies, including, without limitation, the Department of Social Services,
the Department of Revenue, the Department of Mental Health and the Department of
Mental Retardation, medical, hospital, and school records and prior GAL reports, if any.
The Guardian Ad Litem may read (but may not have a copy of) the parties’ criminal
records (CORI/CARI). The Guardian Ad Litem shall have the right to interview any
persons having information as to the contents of said reports.
C. Privileged Information of a Party.
The GAL shall have the right to read and copy a party’s privileged records if that party
provided written consent to the Guardian Ad Litem.
D. Privileged Information of a Child.
□
A Guardian To Waive or Assert the child’s privilege has been appointed by separate
order and has
□ Waived _____________________’s privilege.
□ Asserted _____________________’s privilege.
□ Not yet filed a report. The Guardian to Waive or Assert Privilege shall notify the
parties and the GAL when the report is filed.
□
□
Therefore, the Guardian Ad Litem
shall
shall not
therapist, ______________________and his or her records.
have access to the child’s
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4. DUE DATE FOR REPORT. The Guardian Ad Litem shall, on or before _______________,
file a written report with the court.
5. The Report shall include, in separate sections, the GAL’s inferences and/or conclusions, and
his or her recommendations, if any, based only upon the facts set forth in the body of the
Report.
6. FEE. The fee for services of the Guardian Ad Litem, which shall not, without prior Court
approval, exceed:
□ $600.00 (Paid by Commonwealth)
□ $_______________(Private Pay)
□ $1,000.00 (Paid by Commonwealth, Clinical GAL)
Shall be paid as follows
□ Initially by the Commonwealth of Massachusetts subject to possible recoupment from
the parties at a later date
□ _______% by the Plaintiff
□ _______% by the Defendant
□ Other________________________________________________________________.
Arrangements for payment shall be made directly between the parties and the Guardian Ad
Litem. The Guardian Ad Litem may elect not to begin the investigation until receipt of the
deposit of the fee as set forth above.
7. ACCESS TO THE GUARDIAN AD LITEM’S REPORT
A. Neither party nor a party’s attorney may have access to the report until both parties’
obligations to pay the Guardian Ad Litem’s fee have been fulfilled.
B. Unless otherwise ordered by the Court, each party and each party’s attorney shall have
the right to read and obtain a copy of the Guardian Ad Litem’s report subject to the
following limitations:
1. Each party and each attorney shall make no further copies of the report;
2. Each party and each attorney shall not disclose to any other person the
information contained in the report
3. Each party and each attorney shall sign an agreement in the Probation
Department of the Court as to these requirements of non-disclosure.
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APPOINTMENT FORM WITH BLANK LINES FOR JUDGE TO DEFINE ISSUES
Suffolk Division8
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court Department
Docket No.__________
Appointment of Guardian ad Litem
___________________________________________________, Plaintiff
vs.
___________________________________________________, Defendant
Whereas ○ custody of and/or visitation with children is in issue in this matter,
○ it appears that ____________________________is a person under disability,
therefore____________________________________of______________________________,
in the _____________________County of______________________is appointed to act as
○ guardian ad litem/next friend for such person(s) to represent his—her—the
child(ren)’s interests in said case.
○ guardian ad litem/investigator to investigate and report on the following
issues__________________________________________________________
○ guardian ad litem/evaluator to evaluate and report on the following
issues___________________________________________________________
○ guardian ad litem/next friend to determine whether the patient-psychotherapist
and/or social worker-client privilege of such person should be exercised or
waived.
The guardian ad litem shall report in writing to the court on or before________________
The guardian ad litem shall be paid by: ○ _______________________________________
○ the Commonwealth of Massachusetts.
________hours authorized with leave to
request more by motion if necessary.
Date____________________________
______________________________________
[Printed name of judge]
Justice of the Probate and Family Court
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I accept the above appointment.
(FOR ALL APPOINTMENTS) I understand that, pursuant to Supreme Judicial Court Rule
1:07(7) no payment shall be made to or received by me from any source on account of this
appointment until I have filed the required certification with the court. I certify that I have filed all
of the fee reports required by that rule for payments made to me in the fiscal year previous to
this year.
(FOR COMMONWEALTH PAID ONLY) I acknowledge receipt of Fiscal Year 1997 Memo #14
of the Chief Justice for Administration and Management with the Certificate of Services Form
and Instructions.
(FOR GUARDIAN AD LITEM TO INVESTIGATE ONLY) I acknowledge receipt of Standing
Order 2-98 of the Probate and Family Court Department.
________________________________________________________
(Signature)
________________________________, ss.
________________________________
Personally appeared the above named
______________________________________________ and made their oath that (s)he would
faithfully and impartially perform the duty imposed on him-her by the foregoing appointment.
____________________________________________________
NOTARY PUBLIC
Instructions
Please sign this form, accepting this appointment, before a notary public, have the notarial jurat
completed, and mail this form back to:
CHIEF PROBATION OFFICER
SUFFOLK PROBATE AND FAMILY COURT
24 New Chardon Street
Boston, MA 02114
_______________________________________________
8
This is the standard GAL appointment form used by the Suffolk division of the Massachusetts Probate
and Family Court.
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NARRATIVE APPOINTMENT FORM -- #1
______________Division
State of _____________________
The Trial Court
Probate and Family Court Department
_____________________________ )
Plaintiff )
)
v.
)
)
)
_____________________________ )
Defendant )
Docket No.________
ORDER FOR APPOINTMENT
OF GUARDIAN AD LITEM
Upon the Plaintiff’s Motion for Appointment of Guardian Ad Litem, IT IS ORDERED
THAT:
1. __________________________ is appointed Guardian Ad Litem on behalf of the
parties’ minor children.
2. The Guardian Ad Litem shall investigate and make findings with respect to the legal
and physical custody of the minor children of the parties as well as the appropriate
level and manner of contact between the children and the non-custodial parent.
3. The Guardian Ad Litem shall have the authority to undertake any or all of the
following actions which the Guardian Ad Litem, in her discretion, deems appropriate,
including:
a. Interview the children with or without other persons present;
b. Interview the parents, teachers, day-care providers, medical and/or mental
health professionals, and any other persons who have been involved in caring
for or treating the children.
4. The parties shall fully cooperate with the Guardian Ad Litem’s investigation including,
but not limited to, furnishing all documents requested by the Guardian Ad Litem;
participating in interviews; submitting themselves to independent mental and/or
medical health evaluations and counseling, if required by the Guardian AD Litem;
and making themselves and/or the children available to the Guardian Ad Litem at
such reasonable times and places as she may request for purposes of carrying out
the duties of her appointment.
5. This Order shall serve as authorization by both parties to the release of any and all
documents or information pertaining to either party or the minor children. Upon
presenting a copy of this Order to any agency, hospital, organization, school, person,
or office, the Guardian Ad Litem shall have the right to inspect and copy any and all
records relating to either party or the minor children. The Guardian Ad Litem shall
maintain any information received from any such source as confidential and such
information shall not be disclosed except in reports to the Court, to the parties and
their counsel, or directly by the Court.
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6. A report shall be filed on or before _______________________.
7. On or before _____________________, Mr. ______________________ shall pay
$__________ and Ms. _____________________ shall pay $__________ to the
Probation Office of this Court towards a deposit for said Guardian Ad Litem costs.
The balance, upon filing of said report, shall be paid up to $__________ by Mr.
___________________ and the remaining balance, up to $___________ by Ms.
______________________.
_______________
Date
___________________________________________
Honorable ____________________________
Judge of Probate and Family Court
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NARRATIVE APPOINTMENT FORM -- #29
Commonwealth of Massachusetts
The Trial Court
[Division of Court]
Probate and Family Court Department
Docket No.__________
______________________________
JOHN DOE,
)
Plaintiff
)
)
ORDER APPOINTING A
v.
)
CHILD CUSTODY EVALUATOR
)
JANE DOE,
)
Defendant
)
________________________________ )
After hearing, it appears that the best interests, rights or wishes of the minor child(ren) require
the appointment of a child custody evaluator.
The Court appoints ________________________ to serve in the capacity of child custody
evaluator to evaluate and report back to the Court on issues regarding custody and visitation.
The Court is particularly concerned with possible inappropriate discipline methods of the
Mother, over-involvement of the children in the marital dissolution by the Father, the effects of
split custody and the overall needs of the family.
The child custody evaluator shall have authority to do any and all of the following as he/she
deems necessary and appropriate to prepare a report for the Court:
a.
to contact any or all people having relevant knowledge regarding
any member of the family;
b.
to consult with any professional with specialized knowledge;
c.
to require psychological and/or medical evaluations of any and all family members
and/or caretakers;
The parties are to contact the child custody evaluator and arrange to provide him/her with
whatever information is necessary for him/her to carry out his/her functions. The parties should
arrange for themselves and the child(ren) to go to the child custody evaluator’s office at a time
convenient to him/her and to provide him/her with whatever records she/she requires.
Furthermore, if the child custody evaluator desires, the parties are to make arrangements for
him/her to see the conditions under which the child(ren) live(s). If the child custody evaluator
determines that the child(ren) is/are at risk as a result of the present custodial/visitation
arrangements, he/she may file an interim report with the Court.
Neither party shall submit any written material to the child custody evaluator without
simultaneously submitting it to the other side. The child custody evaluator shall not consider any
written material that does not meet this condition.
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The parties’ counsel shall be entitled to copies of all reports of the child custody evaluator. THE
CONTENTS MAY BE SHARED WITH THEIR CLIENTS, BUT BOTH CLIENTS ARE
PROHIBITED FROM DISCUSSING THE CONTENTS WITH THE CHILD(REN) OR ANY
OTHER THIRD PARTY EXCEPT MENTAL HEALTH PROFESSIONALS. NO COPIES ARE TO
BE GIVEN TO THE CLIENTS. In the event that counsel is discharged prior to trial, counsel
shall return the report to the court.
The final report, which shall be filed as soon as the evaluation is complete, shall make specific
reference to the following factors:
1. The social history of both parties;
2. The marital and parenting history;
3. The history of inter-parental conflict including any incidents of domestic violence;
4. If domestic violence is an issue, consider each parent’s capacity:
a. For impulse control
b. To change problem-solving style
c. To empathize with children
d. To create and maintain a safe environment.
5. The age and developmental state of each child;
6. The health of each child and the parties with particular reference to any special needs or
problems;
7. The interests and activities of each child and the role each party plays in encouraging
and developing such interests;
8. The demonstrated capacity of each party to foster the growth and development of each
child and to understand the individual needs of each child;
9. Each party’s demonstrated ability to provide continuity and stability of environment.
10. The relationship and attachments of each child to his or her parents, siblings, and any
other person who may have a significant effect upon the child;
11. The demonstrated capacity of each of the parties to support an ongoing relationship
between each child and the other parent.
If the child custody evaluator determines that this is a case that is appropriate for mediation,
he/she may make such recommendation to the parties or to the Court.
The child custody evaluator may, in his/her final report, recommend counseling for any or all of
the parties. The report is to be completed within 60 days.
The child custody evaluator is to be paid equally by the parties. Application of any insurance
proceeds shall benefit both parties equally.
The child custody evaluator is not to exceed 20 hours without leave of Court.
__________________________________________________
Judge of Probate
Entered:
cc:
_________ _________________, Child Custody Evaluator
__________________________, Attorney for Plaintiff
__________________________, Attorney for Defendant
9
This appointment form was developed by Hon. Arline S. Rotman (ret.), Massachusetts Probate and
Family Court. Some terms have been changed so that the form can be applied nationally. For instance,
in Massachusetts custody evaluators are appointed as “Guardians Ad Litem,” whereas in other
CD, Section I: Court Appointments
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jurisdictions the term “custody evaluator” is used. This slightly edited version of the original appointment
form is reprinted with the permission of Judge Rotman.
APPOINTMENT FORM REGARDING CHILD/PSYCHOTHERAPIST PRIVILEGE10
COMMONWEALTH of MASSACHUSETTS
The Trial Court
Probate and Family Court
Franklin, ss.
Plaintiff
Docket No. ______________
vs. __________________________Defendant
or
In Re: Guardianship of
APPOINTMENT OF A GUARDIAN
After hearing on
with respect to the______________________________
filed on ___________________, it appears that a Guardian should be appointed to represent
the interests of the minor child(ren):
____________________________________ born ______________________
____________________________________ born ______________________
____________________________________ born ______________________
pursuant to the provisions of G.L. c. 233, §20B and/or G.L. c. 112, §135B, to determine whether
the minor child(ren)’s psychotherapist and/or social worker privilege(s) should be exercised or
waived.
THEREFORE this Court hereby appoints _____________________________________
of ________________________________________________________ as Guardian, to review
the matter, to exercise or waive these or other applicable privileges on behalf of the minor
child(ren), and to file with the Court a written report stating his/her reasons for so doing, on or
before ________________.
The fee for services of the Guardian, which shall not exceed $X,XXX.XX without prior
Court approval, shall be paid by the Commonwealth of Massachusetts initially, subject to
possible recoupment from the parties at a later date.
A _____________________ is scheduled for ____________________ at ____________; a
separate ___________________________________ shall issue with respect thereto.
Date: _________________
__________________
10
This appointment form was developed by Hon. Geoffrey Wilson, Massachusetts Probate and Family
Court. Reprinted with permission of Judge Wilson.
CD, Section I: Court Appointments
page
21
Justice, Probate and Family Court
(see other side)
NOTE: All Guardians
and Guardians ad Litem
*****************
must comply with Supreme Judicial Court Rule
1:07.11
I, _____________________________________________, hereby accept the above
appointment and acknowledge receipt of Fiscal Year 1997 Memo #14.
Date:
_________________________
______________________________________
(signature of person appointed)
*****************
Franklin, ss.
Personally appeared before me the above-named
_____________________________________ and made oath that he would faithfully and
impartially perform the duty imposed on him by the foregoing appointment.
Date: __________________________
__________________________
Register/Judicial Case Manager
****************
I have completed my investigation and have filed a written report as ordered.
Date: _________________________
__________________________________
11
See footnote 6 above.
CD, Section I: Court Appointments
page
(signature of person appointed)
22