REQUEST FOR EMERGENCY HEARING
AFTER INVOLUNTARY ADMISSION TO MENTAL HEALTH FACILITY
G.L. c. 123, § 12(b)

DOCKET NO.  (to be added by court) Trial Court of Massachusetts

District Court Department

                                             District Court

To be completed after consultation with a lawyer, if any, and then filed with the court by FAX and a copy given to the facility Director.

IN THE MATTER OF

NAME OF PATIENT

I, the patient named above, have been involuntarily admitted to                                                                                              .

I hereby request an emergency court hearing because I have reason to believe that my admission resulted from an abuse or
misuse of the admission procedure of Massachusetts General Laws c. 123, § 12(b):

NAME OF FACILITY

1. G The hospital did not inform me of my right to request a lawyer.
2. G The hospital did not notify the Committee for Public Counsel Services of my request to have a lawyer.
3. G The  Committee  for  Public  Counsel  Services  did  not  appoint  a  lawyer  to  represent  me,  or  the  lawyer  appointed  to

represent me did not meet with me.

4. G A psychiatric examination was not conducted by a physician designated by the Department of Mental Health.
5. G A psychiatric examination was not conducted within two hours.
6. G Other abuse or misuse of the § 12(b) admission procedure (describe the alleged abuse or misuse):

Please note that a designated physician’s clinical decision that failure to hospitalize the patient would create a likelihood of serious
harm by reason of mental illness is not subject to review at an emergency hearing.

I give permission to the facility to release my mental health records to the court solely for the purpose of the requested hearing.

DATE SIGNED

COUNSEL’S SIGNATURE (if any)

PATIENT’S SIGNATURE

   X

   X

COURT’S RULING ON REQUEST
To be completed by judge and returned to patient and admitting facility by FAX

Upon review of the above request, the Court hereby ORDERS that:
G   The request for hearing is ALLOWED and a HEARING IS SCHEDULED for ________________________________

G  IN THIS COURT.      G  AT THE FACILITY NAMED ABOVE.
The patient shall be present at such hearing unless through counsel he or she waives the right to be present.

DATE & TIME

G   The request for hearing is DENIED because:

G The above request does not allege any abuse or misuse of the admission procedure of § 12(b).
G Other (describe):

DATE

(rev. 08/08)

JUDGE

   X