Petition for Determination of Incompetency and for Authorization of Medical Treatment for Mental Illness Pursuant to G.L. c. 123, § 8B IN THE MATTER OF CRIMINAL DOCKET NO. (if any) MENTAL HEALTH DOCKET NO. (if any) MASSACHUSETTS TRIAL COURT DOB GENDER Male Female SSN COURT DIVISION PETITIONER TITLE FACILITY I hereby petition this court for a determination in accordance with the applicable provisions of law that the above named Respondent, who is either the subject of a commitment petition or currently committed, is incompetent by reason of being incapable of making informed decisions concerning the medical treatment proposed herein, and that the court, applying the required legal standard, authorizes the following treatment: Treatment with antipsychotic medications, as set forth in the accompanying treatment plan. ECT. Other. The proposed treatment is necessary for the treatment of the Respondent. The Respondent is incapable of making an informed decision about the proposed treatment. If competent, the Respondent would accept the proposed treatment. An affidavit is being filed in further support of this petition. I. FACTORS SUPPORTING A FINDING OF INCOMPETENCY: In support of the request for a determination of the Respondent's incompetence to making informed decisions concerning the proposed medical treatment, the Respondent is unable to appreciate the nature of his/her mental illness, the consequences of the illness, the risks of the illness being left untreated, and the benefits and risks of the proposed medical treatment. Additional factors, if any: II. FACTORS IN SUPPORT OF SUBSTITUTED JUDGMENT: (see Rogers v. Comm'r Dep't Mental Health, 390 Mass. 489 (1983)) Patient's expressed preferences: Respondent's acceptance or refusal of treatment and/or medicine is without understanding of the risks and benefits. I am not aware of any religious beliefs or convictions of the Respondent that would interfere with the acceptance of treatment. I am not aware of any negative impact on the Respondent's relationship with his/her family as a result of his/her acceptance of medical treatment. Any adverse side effects of the medication are outweighed by the benefits of the proposed treatment. The prognosis with treatment is The prognosis without treatment is Other: The record indicates that the nearest relative or guardian of the Respondent is: The Respondent does not speak English. An interpreter fluent in language is requested. Date Signature Please attach the proposed treatment plan, any supporting affidavit(s) and any other relevant documents. (Rev. 4.18.17) American LegalNet, Inc. www.FormsWorkFlow.com