PHONE NUMBER 

1. What is your relationship to the Respondent? How often do you see the person? When did you last see the person? 

AFFIDAVIT IN SUPPORT OF 
PETITION FOR COMMITMENT 
UNDER G.L. c. 123, § 35 

COURT DEPARTMENT 

TRIAL COURT OF 
MASSACHUSETTS 

RESPONDENT'S NAME 

PETITIONER'S NAME 

PETITIONER'S ADDRESS 

2. Reason for the request for the petition. Please check below if the person is abusing alcohol, substances or both. Describe the 

frequency of use, and, if substances are involved, what kind. 

  Alcohol Abuse 

  Substance Abuse 

  Both Alcohol and Substance Abuse 

3. This person is a danger to self or others for the following reasons (for example, overdose, suicide attempt, hospitalization or 

criminal activity). Please provide a detailed explanation including dates of events. 

 

 

 

 

 

 

 

 

 

 

 

 

     

   

   

   

   

   

   

   

   

   

   

   

(Rev. 7/18) 

 

4. Does the Respondent have a history of mental health and/or substance abuse commitments or treatment? If yes, please 

provide a detailed explanation including when, where, and how recent. 

5. Provide any other information you feel will assist the Court in deciding whether or not to commit the Respondent. 

SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY 

DATE 

X 

(Rev. 7/18) 

                           

                                                                                   

 

 



Affidavit in Support of Petition for Commitment Under G.L. c. 123

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.

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About This Form:

• Sourced from www.mass.gov (2023-03)
• Page(s): 2
• Fields(s): 20
• Average fields per page: 10
• Reading Level: Grade 9
• LIST Grouping(s): CO-07-00-00-00, CR-13-00-00-00, CR-00-00-00-00, CO-00-00-00-00.

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