APPLICATION  FOR  3-DAY COMMITMENTFOR  MENTAL ILLNESSG.L. c. 123, § 12(e)  Docket No.     Trial Court of Massachusetts     District Court Department  IN THE MATTER OF (name of respondent) DOB OR AGE  GENDERAPPLICATIONfor 3-day Commitment for Mental IllnessG.L. c. 123,  § 12(e)  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.  Division  Date Signed  Applicant's Signature  Applicant's Printed Name  Applicant's Title or Relationsip, if any, to Respondent       2. Calculation of 3-day period.  Pursuant to G.L. c. 123, § 12(e), the three-day maximum commitment period is computed  pursuant to Mass. R. Civ. P. 6, that is, 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.    http://trialcourtweb.jud.state.ma.us/courtsandjudges/courts/districtcourt/formsfordownload.html  (rev. 10/2006)NOTES       1. G.L. c. 123, § 12(e). "Any person may make application to a district court justice . . . 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 . . . 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 liklihood 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." MALE FEMALEX  SOCIAL SECURITY NUMBER