Civil Commitment and Hospital Admissions Forms

DMH 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.

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.

Spanish Translations

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