Application For 3-Day Commitment For Mental Illness

APPLICATION FOR 3-DAY COMMITMENT FOR MENTAL ILLNESS G.L. c. 123, § 12(e) NAME OF RESPONDENT Docket No. Division DOB OR AGE Trial Court of Massachusetts District Court Department GENDER IN THE MATTER OF MALE FEMALE APPLICATION for 3-day Commitment for Mental Illness G.L. c. 123, § 12(e) The undersigned applicant hereby applies to this court for an order to commit the respondent to a mental health facility for a maximum of three days because the respondent is a mentally ill person and the failure to confine the respondent would cause a likelihood of serious harm. Date Signed Applicant's Signature X Applicant's Printed Name Applicant's Title or Relationsip, if any, to Respondent NOTES 1. G.L. c. 123, § 12(e). "Any person may make application to a district court justice . . . for a three day commitment to a facility of a mentally ill person whom the failure to confine would cause a likelihood of serious harm. The court shall appoint counsel to represent said person. After hearing such evidence as he may consider sufficient, a district court justice . . . may issue a warrant for the apprehension and appearance before him of the alleged mentally ill person, if in his judgment the condition or conduct of such person makes such action necessary or proper. Following apprehension, the court shall have the person examined by a physician designated to have the authority to admit to a facility or examined by a qualified psychologist in accordance with the regulations of the department. If said physician or qualified psychologist reports that the failure to hospitalize the person would create a liklihood of serious harm by reason of mental illness, the court may order the person committed to a facility for a period not to exceed three days, but the superintendent may discharge him at any time within the three day period." 2. Calculation of 3-day period. Pursuant to G.L. c. 123, § 12(e), the three-day maximum commitment period is computed pursuant to Mass. R. Civ. P. 6, that is, without including the day the application was filed or any intervening Saturday, Sunday or legal holiday. If the third day is a Saturday, Sunday or legal holiday, that day is not counted, and the next day that is not a Saturday, Sunday or legal holiday is counted as the third day. http://trialcourtweb.jud.state.ma.us/courtsandjudges/courts/districtcourt/formsfordownload.html (rev. 10/2006) www.FormsWorkFlow.com