PETITION FOR COMMITMENT OF
ALCOHOLIC OR SUBSTANCE ABUSER
G.L. c. 123, § 35

DOCKET NUMBER

Trial Court of Massachusetts
Juvenile Court Department

In the Matter of:

DOB OR AGE

NAME OF RESPONDENT

DIVISION

GENDER

Male

Female

The undersigned petitioner hereby applies to this court for an order committing the respondent named above for
inpatient care and treatment for alcoholism and/or substance abuse for a period not to exceed 90 days under the
provisions of G.L. c. 123, § 35.

The petitioner has reason to believe that there is a likelihood of serious harm as a result of the respondent’s
chronically or habitually consuming or ingesting alcoholic beverages and/or controlled substances or intentionally
inhaling toxic vapors to the extent that such use substantially injures the respondent’s health or substantially
interferes with the respondent’s social or economic functioning, or that the respondent has lost the power of self-
control over use of such beverages and/or substances.

WARRANT OF APPREHENSION

     The petitioner also requests the court to issue a Warrant of Apprehension.  The respondent is unlikely to
appear for an examination and any further delay in the proceedings would present an immediate danger to the
physical well-being of the respondent.

 DATE

PETITIONER'S RELATIONSHIP TO RESPONDENT

SIGNATURE OF PETITIONER
x
PRINT NAME AND TITLE

ADDRESS OF PETITIONER

 TELEPHONE NUMBER:

 CELL PHONE NUMBER:

RESPONDENT INFORMATION

ADDRESS OF RESPONDENT

Complete this Section Only if the Respondent is a Child

Who is the child's legal custodian?

NAME AND ADDRESS OF LEGAL CUSTODIAN IF OTHER THAN PETITIONER

 TELEPHONE NUMBER:

 CELL PHONE NUMBER:

 TELEPHONE NUMBER:

 CELL PHONE NUMBER:

JV-096  (01/02/2013)

INSTRUCTIONS FOR COMMITMENT OF ALCOHOLIC OR SUBSTANCE ABUSER
FOR PURPOSES OF INPATIENT CARE

DEFINITION OF“ALCOHOLIC”:  For the purposes of G. L. c. 123, § 35, "alcoholic'' shall mean a person
who chronically or habitually consumes alcoholic beverages to the extent that (1) such use substantially
injures his health or substantially interferes with his social or economic functioning, or (2) he has lost the
power of self-control over the use of such beverages.

DEFINITION OF“SUBSTANCE ABUSER”:  For the purposes of G. L. c. 123, § 35,"substance abuser'' shall
mean a person who chronically or habitually consumes or ingests controlled substances or who intentionally
inhales toxic vapors to the extent that: (i) such use substantially injures his health or substantially interferes
with his social or economic functioning; or (ii) he has lost the power of self-control over the use of such
controlled substances or toxic vapors.

STATUTORY BASIS FOR COMMITMENT:  Any police officer, physician, spouse, blood relative, guardian
or court official may petition in writing any district court or any division of the juvenile court department for an
order of commitment of a person whom he has reason to believe is an alcoholic or substance abuser.  Upon
receipt of a petition for an order of commitment of a person and any sworn statements the court may
request from the petitioner, the court shall immediately schedule a hearing on the petition and shall cause a
summons and a copy of the application to be served upon the person in the manner provided by section
twenty-five of chapter two hundred and seventy-six.  In the event of the person's failure to appear at the time
summoned, the court may issue a warrant for the person's arrest. Upon presentation of such a petition, if
there are reasonable grounds to believe that such person will not appear and that any further delay in the
proceedings would present an immediate danger to the physical well-being of the respondent, said court
may issue a warrant for the apprehension and appearance of such person before it.  No arrest shall be
made on such warrant unless the person may be presented immediately before a judge of the district court.
The person shall have the right to be represented by legal counsel and may present independent expert or
other testimony.  If the court finds the person indigent, it shall immediately appoint counsel.  The court shall
order examination by a qualified physician or a qualified psychologist.

If, after a hearing and based upon competent testimony, which shall include, but not be limited to, medical
testimony, the court finds that such person is an alcoholic or substance abuser and there is a likelihood of
serious harm as a result of the person's alcoholism or substance abuse, the court may order such person to
be committed for a period not to exceed 90 days, followed by the availability of case management services
provided by the department of public health for up to 1 year; provided, however, that a review of the
necessity of the commitment shall take place by the superintendent on days 30, 45, 60 and 75 as long as
the commitment continues.  A person so committed may be released prior to the expiration of the period of
commitment upon written determination by the superintendent that release of that person will not result in a
likelihood of serious harm.  Such commitment shall be for the purpose of inpatient care in public or private
facilities approved by the department of public health under chapter 111B for the care and treatment of
alcoholism or substance abuse.  The person may be committed to the Massachusetts correctional institution
at Bridgewater, if a male, or at Framingham, if a female, if there are not suitable facilities available under
said chapter 111B; provided, however, that the person so committed shall be housed and treated separately
from convicted criminals.  Such person shall, upon release, be encouraged to consent to further treatment
and shall be allowed voluntarily to remain in the facility for such purpose.

JV-096  (01/02/2013)