Fillable Application For 3-day Commitment For Mental Iillness Jv 113re 2 (Commonwealth of Massachusetts)

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Application For 3-day Commitment For Mental Iillness Jv 113re 2 (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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JV-113 (Rev. 04/26/2013)
APPLICATION FOR 3-DAY
COMMITMENT FOR MENTAL ILLNESS
G.L. c. 123, § 12(e)
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
APPLICANT'S NAME RESPONDENT'S NAME
DATE
SIGNATURE OF APPLICANT
x
GENDER
Male Female
DOB
AGENCY NAME OR APPLICANT'S RELATIONSHIP TO RESPONDENT
RESPONDENT'S ADDRESS AND TELEPHONE NO.
APPLICANT'S ADDRESS AND TELEPHONE NO.
(complete only if respondent is a juvenile)
RESPONDENT'S PARENT(S)' OR GUARDIAN(S)' NAME, ADDRESS AND
TELEPHONE NO.
1.
2.
Who is the legal custodian of the child?
(complete only if respondent is a juvenile)
Has the child been the subject of a juvenile court proceeding?
Yes No
If yes, what type of proceeding: C&P Delinquency
CHINS/Child Requiring Assistance
Name of Court:
What is respondent's current medical condition?
Is respondent currently taking any medication?
Yes No
If yes, list all medications:
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.
TELEPHONE NO.
HOME NO.
WORK NO.
HOME NO.
WORK NO.
HOME NO.
WORK NO.
JV-113 (Rev. 04/26/2013)
INSTRUCTIONS FOR COMMITMENT DUE TO MENTAL ILLNESS
STATUTORY BASIS FOR COMMITMENT: Under G.L. c. 123, §12(e) “any person may make application to
a district court justice or a justice of the juvenile court department 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 or a justice of the juvenile court department 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 likelihood 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. The periods of
time prescribed or allowed under the provisions of this section shall be computed pursuant to Rule 6 of the
Massachusetts Rules of Civil Procedure.”
CALCULATION OF 3-DAY PERIOD: The three day maximum commitment is calculated 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.
LIKELIHOOD OF SERIOUS HARM: Pursuant to G.L. c. 123, § 1, the definition of “likelihood of serious
harm” which in association with mental illness justifies involuntary retention in a mental health or retardation
facility is as follows: “(1) a substantial risk of physical harm to the person himself as manifested by evidence
of, threats of, or attempts at, suicide or serious bodily harm; (2) a substantial risk of physical harm to other
persons as manifested by evidence of homicidal or other violent behavior or evidence that others are placed
in reasonable fear of violent behavior and serious physical harm to them; or (3) a very substantial risk of
physical impairment or injury to the person himself as manifested by evidence that such person’s judgment is
so affected that he is unable to protect himself in the community and that reasonable provision for his
protection is not available in the community.”
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Application For 3-day Commitment For Mental Iillness Jv 113re 2 (Commonwealth of Massachusetts)

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Completed 26 July 2020

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