CRIMINAL DOCKET NO. (if any) Petition for 30 Day Examination and Observation Pursuant to G.L. c. 123, § 18(a) IN THE MATTER OF MENTAL HEALTH DOCKET NO. (if any) MASSACHUSETTS TRIAL COURT DOB GENDER Male Female SSN COURT DIVISION PETITIONER TITLE FACILITY The Petitioner respectfully represents that the he/she is a physician or psychologist qualified by the Department of Mental Health to perform psychiatric examinations of prisoners. The Petitioner has examined the Respondent, a prisoner at said institution, pursuant to a request made by: person in charge of place of detention title name of place of detention A report on the mental condition of said prisoner is attached. The prisoner is currently: a pretrial defendant charged with list charges and docket numbers (This petition to be filed in court of criminal jurisdiction.) OR serving sentence which expires on date sentence expires (This petition to be filed in court with jurisdiction over place of detention.) I believe the prisoner should be committed to not to exceed 30 days for observation, for the following reasons: facility , for a period Therefore, I request the Court order such commitment. Date Signature Print Name Title Please attach report from place of detention. (Rev. 1.26.17) American LegalNet, Inc. www.FormsWorkFlow.com