disclosures: 06705f7d871ce67debd5c57aba1717e8ae58535f4047a7f943704437bd926d14
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| 06705f7d871ce67debd5c57aba1717e8ae58535f4047a7f943704437bd926d14 | 2025/Henry,_Melissa_930CMR6.07_disclosure_1.16.25.pdf | 2025 | Melissa O. Henry, Psy.D. 2025 JAN 16 AM 24 | Department of Mental Health | DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SOCIAL SERVICES PURSUANT TO 930 CMR 6:07CEIVED STATE ETHICS COMMISSION STATE EMPLOYEE INFORMATION Name of state Melissa O. Henry, Psy.D. 2025 JAN 16 AM 24 employee: Title/ Position: Forensic Psychologist Agency/Department: Department of Mental Health Agency Address: 25 Staniford Street, Boston MA 02114 Office phone: 508-454-0751 Office e-mail Melissa.o.henry@mass.gov I am a state employee, and I seek to have a financial interest in a contract or agreement made by a state agency listed below, or by a provider or organization funded by a state agency listed below: A state agency within the following Executive Offices: Executive Office of Health and Human Services, including the Human Service Transportation Office; Executive Office of Public Safety and Security, Executive Office of Elder Affairs, Executive Office of Veteran's Services, or A sheriff's office. The purpose of the contract is: - To provide personal services to a person or persons who receive services from, or have services paid for by, these state agencies; or To provide educational services to people who work for these state agencies or for providers or organizations funded by these state agencies. I seek approval of the arrangement from the agency for which I serve as a state employee and from the state agency above that made the contract. FINANCIAL INTEREST IN A CONTRACT WITH A STATE AGENCY PLEASE CHECK OFF ONE OF THE THREE STATEMENTS BELOW AND PROVIDE THE REQUESTED INFORMATION. 1) Service to a state agency I will provide personal or educational services to a state agency listed above. Please identify the state agency and also the Executive Office it is in, if applicable. 2) Service to a provider or I will provide personal or educational services to a provider or organization funded by a state organization agency listed above. Please provide the name and address of the provider or organization. University of Massachusetts Chan Medical School Psychiatry Department 55 Lake Avenue Worcester, MA 01655 Please identify the state agency that funds the provider or organization, and also the Executive Office it is in, if applicable. Department of Mental Health Executive Office of Health and Human Services 3) Service to a person or persons I will provide personal services directly to a person or persons who receive services from, or have services paid for by, a state agency listed above. Please identify the state agency that provides services to, or pays for services for, the person or persons, and also the Executive Office it is in, if applicable. Please describe the Please provide information about the type of personal or educational services you will provide. services you will Please do not include the name of any individual who receives services. provide. As a consultant, I will provide Forensic evaluation services to the University of Massachusetts Medical School (University) at Worcester Recovery Center and Hospital (WRCH) and Tewksbury State Hospital. These services will include Forensic Evaluations pursuant to M.G.L. Chapter 123, and other evaluations as requested by UMMS, as well as court testimony if required. The University of Massachusetts Medical School Director of the Mobile Forensic Evaluation Service will determine the need for these evaluations. What will you be Please include a dollar amount, if possible. paid, or what other Approximately 4 - 10 evaluations over a 12-month period at a rate of $1000 - $2,400 per financial interest will evaluation, dependent on the need as determined by the University of Massachusetts you have? Medical School Director of the Mobile Forensic Evaluation Service Employee signature Date: APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of Karin D. Towers, J.D., Ph.D., ABPP (Forensic) appointing authority Interim Area Forensic Director Central MA NancyConnolly,PoyD ,Connolly, PsyD Office phone (617) 356-5664 617-626-8258 Office e-mail karin.towers@mass.gov nancy.conaolly@mass.gov. Signature by By signing here, I indicate that I have reviewed the facts that the state employee has appointing authority disclosed above and approve the arrangement proposed by the state employee. Date: Nancy Connolly, PsyD 12/17/24 APPROVAL BY AGENCY THAT MADE THE CONTRACT (IF DIFFERENT) Name and title of Andrea Dinsmore, PsyD, DFP, ABPP person giving Director, University of Massachusetts Chan Medical School Mobile Forensic Service approval at the state agency that made the contract Office phone (774)420-3119 Office e-mail andrea.dinsmore@mass.gov Signature by person By signing here, I indicate that I have reviewed the facts that the state employee has giving approval disclosed above and approve the arrangement proposed by the state employee. Date: 11.21.24 Attach additional pages if necessary. File with: State Ethics Commission One Ashburton Place, Room 619 Boston, MA 02108 Form revised February, 2012 | 2025/Henry,_Melissa_930CMR6.07_disclosure_1.16.25.pdf |