APPLICATION FOR 3-DAY COMMITMENT
FOR MENTAL ILLNESS
G.L. c. 123,
§ 12(e)
Trial Court of Massachusetts
District Court Department
IN THE MATTER OF (name of respondent)
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.
Applicant's Title or Relationsip, if any, to Respondent
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)
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."
