Civil Commitment and Hospital Admissions Forms

The list below contains the English and Spanish versions of downloadable application forms and notification forms related to mental health services civil commitment and hospitalization.

NOTICE OF STATUTE CHANGE AND FORMS REVISIONS

In December 2004, Governor Romney signed Chapter 410 of the Acts and Resolves of 2004, which modifies the Civil Commitment Reform time frames for Section 12(b) and 12(e) admissions. Specifically, effective March 2, 2005, emergency hospitalizations (commitments) under Section 12(b) and 12(e) will be authorized for three (3) business days instead of four (4) business days. Further, the time frame for holding a judicial hearing will increase to from four (4) to five (5) business days from the date a petition for commitment is filed.

Please note that for the first form listed below, Application for and Authorization of Temporary Involuntary Hospitalization (AA-4 Form), Side One (1) can only be completed and signed by a Massachusetts licensed physician, licensed psychologist, licensed and certified psychiatric nurse mental health clinical specialist, licensed independent clinical social worker or police officer, pursuant to Massachusetts General Laws, Chapter 123, Section 12 (a), to apply for temporary involuntary hospitalization. Side Two (2) must be completed by a "designated physician" at the facility with the authority to authorize admissions, pursuant to M.G.L. C. 123, S. 12 (b).

The remaining forms are used by hospitals in Massachusetts for patients who have been admitted for temporary involuntary hospitalization, pursuant to M.G.L., C. 123, S. 12 (b), for patients applying for care and treatment on a conditional voluntary basis, pursuant to M.G.L., C. 123, SS. 10 & 11, or to notify a patient of the hospital's intent to transfer him/her to another facility, pursuant to M.G.L. C. 123, S. 3.

• Application for and Authorization of Temporary Involuntary Hospitals (AA-4 Form) (PDF) 

• Authorization For Transport of a Hospitalized Mentally Ill Person From a Facility (BB-303) Form) (PDF) 

• Application for Care and Treatment on a Conditional Voluntary Basis (CV-300 Conditional Voluntary Form) (PDF) 

• Application for Care and Treatment of a Minor Under Sixteen (16) Years of Age (CV-300G Form for Parent/Guardian) (PDF) 

• Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Conditional Voluntary Hospitalization <br clear= 

• Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301G Form for Parent/Guardian) (PDF) 

• Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Conditional Involuntary Hospitalization <br clear= 

• Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian) (PDF) 

• Notification of Transfer of Mental Health Facility (NT-3) (PDF) 

Spanish Translation

• Solicitud de cuidado y tratamiento como paciente voluntario condicional (CV-300) 

• Solicitud de cuidado y tratamiento como paciente voluntario condicional Leyes Generales de Massachusetts, Capítulo 123, Secciones 10 y 11 (a ser rellenada por un tutor legal con poder para authorizar el ingreso) (CV-300G) 

• NOTIFICACIÓN DE DERECHOS (CV-301) 

• NOTIFICACIÓN DE DERECHOS (Padre o madre de un menor de edad o tutor legal con autoridad para ingresar al paciente) Hospitalización voluntaria condicional Leyes Generales de Massachusetts, Capítulo 123, Secciones 10 y 11 (CV-301G) 

• NOTIFICACIÓN DE DERECHOS (CV-302) 

• NOTIFICACIÓN DE DERECHOS (CV-302G-12b) 

• NOTIFICACIÓN DE TRASLADO 

This information is provided by the Department of Mental Health