Petition for Commitment Pursuant to 
G.L. c. 123, § 16(c) of Defendant Found
to be Incompetent or Not Guilty by
Reason of Mental Illness or Defect

CRIMINAL DOCKET NO. (if any) 

MENTAL HEALTH DOCKET NO. (if any) 

MASSACHUSETTS TRIAL COURT 

IN THE MATTER OF 

PETITIONER

DOB 

TITLE

GENDER 

SSN 

 Male 

 Female

FACILITY

COURT DIVISION (court of facility 
jurisdiction)

The Respondent was charged with the crime(s) of 
On 
mental illness or defect by the 
The Respondent is a patient in 

, the Respondent was found  

date 

court of criminal jurisdiction 

facility 

. 

 

. 

. (Attach copy of 

incompetent to stand trial   not guilty by reason of 

prior G.L. c. 123, §§ 16(b) or 16(c) order of commitment or other writing indicating authority under which 
the Respondent is being detained). 
The Court is being petitioned for the commitment of the Respondent to this or another facility of, or 
licensed by, the Department of Mental Health, or to Bridgewater State Hospital, for his or her retention 
therein until such time as there is not a likelihood of serious harm by reason of mental illness if (s)he is 
not hospitalized for a period of up to 1 year, or the Respondent becomes competent to stand trial, 
whichever is less. 
Your Petitioner has determined that failure to hospitalize the Respondent would create a likelihood of 
serious harm by reason of mental illness, and in support thereof states the following: 

 1. The Respondent is mentally ill by reason of a "substantial disorder" within the meaning of 104

CMR 27.05, namely:

 2. By virtue of said disorder, there is, as defined in G.L. c. 123, § 1, a likelihood of serious harm,
specifically (check appropriate selection(s) below, and where applicable describe evidence of
prior behavior or affected judgment to support each belief):
 A substantial risk of physical harm to the Respondent himself or herself, which has been
manifested by threats of, or attempts at, suicide or serious bodily harm, specifically:

  A substantial risk of physical harm to other persons, which has been manifested by homicidal 
or other violent behavior or by others being placed in reasonable fear of both violent behavior 
and serious physical harm to them or specifically: 

  A very substantial risk of physical impairment or injury to the Respondent himself or herself as 
manifested by evidence that the Respondent's judgment is so affected that he or she is unable to 
protect himself or herself in the community, namely: 

  

 3. (If a Bridgewater commitment is requested) The Respondent is a male and needs strict security

because:

 4. (If commitment to any other facility is requested) There is no less restrictive alternative to

hospitalization appropriate for the Respondent.

  The record indicates that the nearest relative or guardian of the Respondent is: 

  The Respondent does not speak English. An interpreter fluent in 

is requested. 

name and address 

Print Name 

language

Title 

Date 

Signature 

(Rev. 1.26.17)