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COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF MENTAL HEALTH

APPLICATION FOR AN AUTHORIZATION OF TEMPORARY INVOLUNTARY HOSPITALIZATION

M.G.L. Chapter 123, Sections 12 (a) and 12 (b)

Application Pursuant to 12 (a)

): ________________________________________________

1). Application to (Facility name

2). I hereby apply for admission of (name of individual): _______________________________________

Address:_________________________City/Town_________________________State_____________

Social Security Number: __________________ Date of Birth: _____________ Sex: M

to the facility named above pursuant to M.G.L. c. 123, s. 12 (a). I hereby authorize transport and the use of restraint of

the person named above but only if necessary for the safety of the person being transported or of others who are likely

to come into contact with him or her. M.G.L. Chapter 123, s. 21.

Based on my examination

, it is my opinion that the person requires hospitalization at the above named facility so as to

avoid the likelihood of serious harm by reason of mental illness. Evidence supporting my opinion includes:

A). Mental Illness: For purposes of admission to an inpatient facility under Section 12, “Mental Illness” means a

substantial disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior,

capacity to recognize reality or ability to meet the ordinary demands of life. Symptoms caused solely by alcohol or drug

intake, organic brain damage or intellectual disability do not constitute a serious mental illness. Specify evidence

including behavior and symptoms:

_______________________________________________________________________________________

B). Likelihood of Serious Harm (check all categories that apply):

_____ (1) Substantial risk of physical harm to the person himself/herself as manifested by evidence of threats of, or

attempts at suicide or serious bodily harm; and/or

_____ (2) 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; and/or

_____ (3) Very substantial risk of physical impairment or injury to the person himself/herself as manifested by evidence

that such person’s judgment is so affected that he/she is unable to protect himself/herself in the community and

the reasonable provision of his/her protection is not available in the community.

Specify evidence including behavior and symptoms:______________________________________________________

_______________________________________________________________________________________

3). Applicant Certification (check all applicable boxes)

a. I am a:

Licensed Physician or Nurse Practitioner (GL. Ch 112 §80i)

Qualified (

) Psychologist

i.e. Licensed

Qualified

) Psychiatric Nurse Mental Health Clinical Specialist

(i.e. Licensed and Certified

Police Officer

Licensed Independent Clinical Social Worker (LICSW)

b. I have

I have not

personally examined this person. If not, why? ________________________________

______________________________________________________________________________________________

I have consulted with either the receiving facility or emergency screening program.

I have not so consulted because__________________________________________________

____________________________________________________________________________________

Applicant’s name (not patient):

(print)__________________________________________Phone:_______________________________

Address:_____________________________________City/Town_______________________State____

________

Applicant’s signature:_____________________________ Date: _________________ Time:

hospitalization.

NOTE: Parts 1) through 3), above, must be completed to apply for involuntary

Form AA-5

See Reverse for Section 12(b)

Effective – September 25, 2013

If an examination is not possible because of the emergency nature of the case and because of the refusal of the person to consent to such

examination, the physician, qualified psychologist, qualified psychiatric nurse mental health clinical specialist or licensed independent clinical

social worker on the basis of the facts and circumstances may determine that hospitalization is necessary and may apply therefore. G.L.

c.123 s.12(a)

Form Aa-5 - Application For And Authorization Of Temporary Involuntary Hospitalization - Massachusetts Department Of Mental Health

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