CRIMINAL DOCKET NO. (if any) Petition for Commitment Pursuant to G.L. c. 123, §§ 7 & 8 IN THE MATTER OF MENTAL HEALTH DOCKET NO. (if any) MASSACHUSETTS TRIAL COURT DOB GENDER Male Female SSN COURT DIVISION PETITIONER TITLE FACILITY The Respondent is a patient in pursuant to G.L. c. 123, facility § and that the period during which (s)he may be retained thereunder expires on (attach copy of prior order or commitment or other writing indicating authority under which the date Respondent is being retained). 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: name and address The Respondent does not speak English. An interpreter fluent in language is requested. Title American LegalNet, Inc. www.FormsWorkFlow.com Date Signature Print Name (Rev. 1.26.17)