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Here is the text we could read:

CRIMINAL DOCKET NO. (if any)

Petition for Commitment
Pursuant to G.L. c. 123, §§ 7 & 8

MENTAL HEALTH DOCKET NO. (if any)

MASSACHUSETTS TRIAL COURT

IN THE MATTER OF

PETITIONER

DOB

TITLE

GENDER

SSN

Male

Female

FACILITY

COURT DIVISION

The Respondent is a patient in
§
(attach copy of prior order or commitment or other writing indicating authority under which the date
Respondent is being retained).

and that the period during which (s)he may be retained thereunder expires on

facility

pursuant to G.L. c. 123,

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

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.

Date

Signature

Print Name

language

Title

name and address

(Rev. 1.26.17)

Petition for Commitment Pursuant to G.L. c. 123

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 1
Fields(s): 38
Average fields per page: 38
Reading Level: Grade 12
LIST Grouping(s): Unknown

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

crimina_l_docke_n was CRIMINAL DOCKET NO if any (0.65 conf)
menta_l_healt_h_docke_n was MENTAL HEALTH DOCKET NO if any (0.45 conf)
n_th_e_matte_r was IN THE MATTER OF (0.45 conf)
users1_birthdate was DOB (1.00 conf)
ssn was SSN (0.34 conf)
cour_division was COURT DIVISION (0.41 conf)
petitioners1_name was PETITIONER (1.00 conf)
title__1 was TITLE (0.27 conf)
facility__1 was FACILITY (0.33 conf)
respondent_patient was The Respondent is a patient in (0.36 conf)
facility__2 was facility (0.33 conf)
pursuant_g_l_c was pursuant to GL c 123 (0.45 conf)
time_serious_reason was therein until such time as there is not a likelihood of serious harm by reason of mental illness if she is (0.35 conf)
ill_reason_meaning was 1 The Respondent is mentally ill by reason of a substantial disorder within the meaning of 104 (0.38 conf)
risk_physical_harm was A substantial risk of physical harm to the Respondent himself or herself which has been (0.41 conf)
threats_bodily_harm was manifested by threats of or attempts at suicide or serious bodily harm specifically (0.43 conf)
behavior_others_fear was or other violent behavior or by others being placed in reasonable fear of both violent behavior (0.38 conf)
serious_physical_harm was and serious physical harm to them or specifically (0.49 conf)
evidence_judgment_affected was manifested by evidence that the Respondents judgment is so affected that he or she is unable to (0.47 conf)
protect_community_namely was protect himself or herself in the community namely (0.34 conf)
commitment_requested_strict was 3 If a Bridgewater commitment is requested The Respondent is a male and needs strict security (0.38 conf)
indicates_nearest_relative was The record indicates that the nearest relative or guardian of the Respondentis (0.32 conf)
speak_english_fluent was The Respondent does not speak English An interpreter fluent in (0.39 conf)
signature_date was Date (1.00 conf)
users1_signature was Signature (1.00 conf)
print_name was Print Name (0.42 conf)
title__2 was Title (0.27 conf)
check_box__1 was Check Box1 (0.52 conf)
check_box__2 was Check Box2 (0.37 conf)
check_box__3 was Check Box3 (0.37 conf)
check_box__4 was Check Box4 (0.37 conf)
check_box__5 was Check Box5 (0.37 conf)
check_box__6 was Check Box6 (0.37 conf)
check_box__7 was Check Box7 (0.37 conf)
check_box__8 was Check Box8 (0.37 conf)
check_box__9 was Check Box9 (0.37 conf)
check_box__10 was Check Box10 (0.37 conf)
check_box__11 was Check Box11 (0.37 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition for Commitment Pursuant to G.L. c. 123

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02