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.
For contact information, please see the DMH Liaison List For Hospitals.
NOTICE OF STATUTE CHANGE AND FORMS REVISIONS
Sections 41 through 45 of Chapter 260 of the Acts of 2020 amended G.L. Ch 123 to replace the title Psychiatric Nurse Mental Health Clinical Specialist with Advanced Practice Registered Nurse. In accordance with its regulatory authority, DMH has promulgated regulations identifying which functions under Chapter 123 may be carried out by any Advanced Practice Registered Nurse and which may be carried out only by a Psychiatric Advanced Practice Registered Nurse. The revised forms listed below make the necessary distinctions where applicable.
For instance, Massachusetts General Laws Chapter 123, Section 12(a) provides that an Application for Temporary Involuntary Hospitalization (AA-5 Form, Side 1), can only be completed and signed by a Massachusetts licensed physician, licensed psychologist, licensed an advanced practice registered nurse. The authorization to admit a patient pursuant to Section 12(b) (Side Two (2) of Form AA-5) can only be signed by physician or qualified advanced practice registered nurse, authorized, as applicable, by the Department pursuant to 104 CMR 33.00. The form has been revised to reflect these provisions of law.
The remaining forms have also been amended as necessary to conform to these changes in law and 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.
The forms are formatted so they can be filled out on line and then downloaded or filed electronically, or can be printed and filled out by hand.
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- 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)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Involuntary Hospitalization (302-12b)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian) (PDF)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3) (PDF)
Spanish Translations
- SOLICITUD DE AUTORIZACIÓN DE HOSPITALIZACIÓN TEMPORAL INVOLUNTARIA (AA-5)
- Solicitud de cuidado y tratamiento como paciente voluntario condicional (CV-300)
- Solicitud de cuidado y tratamiento como paciente voluntario condiciona - hecha por el representante para la atención médical (CV-300 - HCA)
- 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 - representante para la atención médica (CV-301HCA)
- NOTIFICACIÓN DE DERECHOS (CV-302)
- NOTIFICACIÓN DE DERECHOS (CV-302G-12b)
- NOTIFICACIÓN DE DERECHOS (CV-302HCA-12b)
- NOTIFICACIÓN DE TRASLADO
- AUTORIZACIÓN PARA EL TRANSPORTE DE UNA PERSONA HOSPITALIZADA CON UNA ENFERMEDAD MENTAL DESDE UN CENTRO (BB-303)
Haitian Creole Translations
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- 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)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Involuntary Hospitalization (302-12b)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian) (PDF)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3) (PDF)
Portuguese Translations
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- Authorization For Transport of a Hospitalized Mentally Ill Person From a Facility (BB-303) Form)
- Application for Care and Treatment on a Conditional Voluntary Basis (CV-300 Conditional Voluntary Form)\
- Application for Care and Treatment of a Minor Under Sixteen (16) Years of Age (CV-300G Form for Parent/Guardian) (PDF)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3) (PDF)
Chinese Traditional Translations
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- Authorization For Transport of a Hospitalized Mentally Ill Person From a Facility (BB-303 Form)
- Application for Care and Treatment on a Conditional Voluntary Basis (CV-300 Conditional Voluntary Form)
- Application for Care and Treatment of a Minor Under Sixteen (16) Years of Age (CV-300G Form for Parent/Guardian)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3)
Chinese Simplified Translations
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- Authorization For Transport of a Hospitalized Mentally Ill Person From a Facility (BB-303) Form)
- Application for Care and Treatment on a Conditional Voluntary Basis (CV-300 Conditional Voluntary Form)
- Application for Care and Treatment of a Minor Under Sixteen (16) Years of Age (CV-300G Form for Parent/Guardian)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3)
Vietnamese Translations
- Application for and Authorization of Temporary Involuntary Hospitalization (AA-5 Form)
- Authorization For Transport of a Hospitalized Mentally Ill Person From a Facility (BB-303) Form)
- 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)
- Application for Care and Treatment on a Conditional Voluntary Basis - Made By Health Care Agent (CV-300HCA)
- Notice of Rights to All Parents of a Minor or Legal Guardian with Authority to Admit (CV-301P/G Form for Parent/Guardian)
- Notice of Rights to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301)
- Notice of Rights (Health Care Agent) to All Patients Sixteen (16) Years of Age and Older Regarding Temporary Voluntary Hospitalization (CV-301HCA)
- Notice of Rights to All Parents or Guardians of a Minor Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form for Parent/Guardian)
- Notice of Rights to All Patients Regarding Conditional Involuntary Hospitalization (CV-302G-12b Form)
- Notice of Rights (Health Care Agent) to All Patients Regarding Conditional Voluntary Hospitalization (CV-302G-12b-HCA Form for Health Care Agent)
- Notification of Transfer of Mental Health Facility (NT-3) (PDF)