CRIMINAL DOCKET NO. (if any) Petition for Commitment 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 Respondent is a prisoner in (Attach a copy of prior order of commitment or other writing indicating authority under which the Respondent is being retained), and who has been examined and observed at this place of detention. The Petitioner is requesting commitment of the Respondent to this or any other facility of, or licensed by, the Department of Mental Health or to Bridgewater State Hospital, and for his/her retention therein until such time as there is not a likelihood of serious harm by reason of mental illness if he/she is not hospitalized, or for the period of up to 6 months or 1 year , whichever is less. The 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 sections, and where applicable, describe evidence of prior behavior and/or affected judgment supporting such belief): A substantial risk of physical harm to the Respondent himself, 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 or other violent behavior or by being placed in reasonable fear of violent and serious physical harm to others, specifically: 3. There is no less restrictive alternative to hospitalization appropriate for the Respondent. 4. If a commitment to Bridgewater State Hospital is requested: The Respondent is not a proper subject for commitment to any facility of the Department of Mental Health, and failure to confine him/her in strict security would create a likelihood of serious harm to him/herself or others, and The Commissioner of Correction certifies that the Respondent's confinement to Bridgewater State Hospital is necessary to ensure his/her continued retention in custody. (Attach the certification). The records indicate that the nearest relative or guardian of the Respondent is: name and address The Respondent does not speak English. An interpreter fluent in is requested. language Date Signature Title (Rev. 1.26.17) American LegalNet, Inc. www.FormsWorkFlow.com