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Here is the text we could read:

APPLICATION FOR 3-DAY
COMMITMENT FOR MENTAL ILLNESS
G.L. c. 123, § 12(e)

DOCKET NUMBER

Trial Court of Massachusetts
Juvenile Court Department

APPLICANT'S NAME

RESPONDENT'S NAME

AGENCY NAME OR APPLICANT'S RELATIONSHIP TO RESPONDENT

RESPONDENT'S ADDRESS AND TELEPHONE NO.

DOB

GENDER

Male

Female

TELEPHONE NO.

(complete only if respondent is a juvenile)
RESPONDENT'S PARENT(S)' OR GUARDIAN(S)' NAME, ADDRESS AND
TELEPHONE NO.

APPLICANT'S ADDRESS AND TELEPHONE NO.

HOME NO.

WORK NO.

(complete only if respondent is a juvenile)
Has the child been the subject of a juvenile court proceeding?
Yes No

If yes, what type of proceeding: C&P Delinquency
CHINS/Child Requiring Assistance

HOME NO.

WORK NO.

HOME NO.

WORK NO.

What is respondent's current medical condition?

Is respondent currently taking any medication? Yes No
If yes, list all medications:

Name of Court:

Who is the legal custodian of the child?

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.

DATE

SIGNATURE OF APPLICANT

JV-113 (Rev. 04/26/2013)

INSTRUCTIONS FOR COMMITMENT DUE TO MENTAL ILLNESS

STATUTORY BASIS FOR COMMITMENT: Under G.L. c. 123, §12(e) “any person may make application to
a district court justice or a justice of the juvenile court department 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 or a justice of the juvenile court department 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 likelihood 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. The periods of
time prescribed or allowed under the provisions of this section shall be computed pursuant to Rule 6 of the
Massachusetts Rules of Civil Procedure.”

CALCULATION OF 3-DAY PERIOD: The three day maximum commitment is calculated 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.

LIKELIHOOD OF SERIOUS HARM: Pursuant to G.L. c. 123, § 1, the definition of “likelihood of serious
harm” which in association with mental illness justifies involuntary retention in a mental health or retardation
facility is as follows: “(1) a substantial risk of physical harm to the person himself as manifested by evidence
of, threats of, or attempts at, suicide or serious bodily harm; (2) a 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; or (3) a very substantial risk of
physical impairment or injury to the person himself as manifested by evidence that such person’s judgment is
so affected that he is unable to protect himself in the community and that reasonable provision for his
protection is not available in the community.”

JV-113 (Rev. 04/26/2013)

Application for 3-Day Commitment for Mental Illness

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 2
Fields(s): 45
Average fields per page: 22
Reading Level: Grade 12
LIST Grouping(s): Unknown

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

form_petition_docket was form1[0].Petition[0].DocketNo\.[0] (0.54 conf)
form_petition_case_name__1 was form1[0].Petition[0].CaseName[0] (0.36 conf)
form_petition_text_field__1 was form1[0].Petition[0].TextField12[0] (0.41 conf)
form_petition_resp_address_r__1 was form1[0].Petition[0].RespAddress[0].RAddress1[0] (0.37 conf)
form_petition_resp_address_r__2 was form1[0].Petition[0].RespAddress[0].RAddress2[0] (0.37 conf)
form_petition_resp_address_r__3 was form1[0].Petition[0].RespAddress[0].RAddress3[0] (0.37 conf)
form_resp_address_r_phone was form1[0].Petition[0].RespAddress[0].RPhoneNum[0] (0.39 conf)
form_petition_app_address__1 was form1[0].Petition[0].AppAddress[0].Address1[0] (0.37 conf)
form_petition_app_address__2 was form1[0].Petition[0].AppAddress[0].Address2[0] (0.37 conf)
form_petition_app_address__3 was form1[0].Petition[0].AppAddress[0].Address3[0] (0.37 conf)
form_petition_address_home_phone was form1[0].Petition[0].AppAddress[0].HomePhoneNum[0] (0.33 conf)
form_petition_app_address_wo_rk_phone_num was form1[0].Petition[0].AppAddress[0].WoRkPhoneNum[0] (0.38 conf)
form_parent_g_u_address_pg__1 was form1[0].Petition[0].ParentGU1Address[0].PGU1Address1[0] (0.37 conf)
form_parent_g_u_address_pg__2 was form1[0].Petition[0].ParentGU1Address[0].PGU1Address2[0] (0.37 conf)
form_parent_g_u_address_pg__3 was form1[0].Petition[0].ParentGU1Address[0].PGU1Address3[0] (0.37 conf)
form_parent_u_address_home_phone__1 was form1[0].Petition[0].ParentGU1Address[0].PGU1HomePhoneNum[0] (0.36 conf)
form_u_address_pg_wo_phone__1 was form1[0].Petition[0].ParentGU1Address[0].PGU1WoRkPhoneNum[0] (0.36 conf)
form_parent_g_u_address_pg__4 was form1[0].Petition[0].ParentGU2Address[0].PGU2Address1[0] (0.43 conf)
form_parent_g_u_address_pg__5 was form1[0].Petition[0].ParentGU2Address[0].PGU2Address2[0] (0.43 conf)
form_parent_g_u_address_pg__6 was form1[0].Petition[0].ParentGU2Address[0].PGU2Address3[0] (0.43 conf)
form_parent_u_address_home_phone__2 was form1[0].Petition[0].ParentGU2Address[0].PGU2HomePhoneNum[0] (0.43 conf)
form_u_address_pg_wo_phone__2 was form1[0].Petition[0].ParentGU2Address[0].PGU2WoRkPhoneNum[0] (0.38 conf)
form_petition_text_field__2 was form1[0].Petition[0].TextField13[0] (0.41 conf)
form_petition_check_box__1 was form1[0].Petition[0].CheckBox1[0] (0.38 conf)
form_petition_data_drop_list was form1[0].Petition[0].DataDropDownList[0] (0.36 conf)
form_petition_case_name__2 was form1[0].Petition[0].CaseName[1] (0.36 conf)
form_petition_check_box__2 was form1[0].Petition[0].CheckBox1[1] (0.38 conf)
form_petition_check_box__3 was form1[0].Petition[0].CheckBox1[2] (0.38 conf)
form_petition_text_field__3 was form1[0].Petition[0].TextField4[0] (0.41 conf)
form_petition_text_field__4 was form1[0].Petition[0].TextField4[1] (0.41 conf)
form_petition_text_field__5 was form1[0].Petition[0].TextField4[2] (0.41 conf)
form_petition_text_field__6 was form1[0].Petition[0].TextField4[3] (0.41 conf)
form_petition_check_box__4 was form1[0].Petition[0].CheckBox1[3] (0.38 conf)
form_petition_check_box__5 was form1[0].Petition[0].CheckBox1[4] (0.38 conf)
form_petition_check_box__6 was form1[0].Petition[0].CheckBox1[5] (0.38 conf)
form_petition_text_field__7 was form1[0].Petition[0].TextField13[1] (0.41 conf)
form_petition_text_field__8 was form1[0].Petition[0].TextField13[2] (0.41 conf)
form_petition_text_field__9 was form1[0].Petition[0].TextField13[3] (0.41 conf)
form_petition_text_field__10 was form1[0].Petition[0].TextField13[4] (0.41 conf)
form_petition_check_box__7 was form1[0].Petition[0].CheckBox1[6] (0.38 conf)
form_petition_check_box__8 was form1[0].Petition[0].CheckBox1[7] (0.38 conf)
form_petition_check_box__9 was form1[0].Petition[0].CheckBox1[8] (0.38 conf)
form_petition_text_field__11 was form1[0].Petition[0].TextField13[5] (0.41 conf)
form_petition_text_field__12 was form1[0].Petition[0].TextField12[1] (0.41 conf)
form_petition_text_field__13 was form1[0].Petition[0].TextField13[6] (0.41 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Application for 3-Day Commitment for Mental Illness

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02