DOCKET NO. (to be added by court) REQUEST FOR EMERGENCY HEARING Trial Court of Massachusetts District Court Department AFTER INVOLUNTARY ADMISSION TO MENTAL HEALTH FACILITY G.L. c. 123, § 12(b) District Court To be completed after consultation with a lawyer, if any, and then filed with the court by FAX and a copy given to the facility Director. NAME OF PATIENT IN THE MATTER OF I, the patient named above, have been involuntarily admitted to . NAME OF FACILITY I hereby request an emergency court hearing because I have reason to believe that my admission resulted from an abuse or misuse of the admission procedure of Massachusetts General Laws c. 123, § 12(b): 1. 2. 3. 4. 5. 6. G G G The hospital did not inform me of my right to request a lawyer. G G G A psychiatric examination was not conducted by a physician designated by the Department of Mental Health. The hospital did not notify the Committee for Public Counsel Services of my request to have a lawyer. The Committee for Public Counsel Services did not appoint a lawyer to represent me, or the lawyer appointed to represent me did not meet with me. A psychiatric examination was not conducted within two hours. Other abuse or misuse of the § 12(b) admission procedure (describe the alleged abuse or misuse): Please note that a designated physician’s clinical decision that failure to hospitalize the patient would create a likelihood of serious harm by reason of mental illness is not subject to review at an emergency hearing. I give permission to the facility to release my mental health records to the court solely for the purpose of the requested hearing. DATE SIGNED COUNSEL’S SIGNATURE (if any) PATIENT’S SIGNATURE X X COURT’S RULING ON REQUEST To be completed by judge and returned to patient and admitting facility by FAX Upon review of the above request, the Court hereby ORDERS that: G The request for hearing is ALLOWED and a HEARING IS SCHEDULED for ________________________________ G IN THIS COURT. G AT THE FACILITY NAMED ABOVE. DATE & TIME The patient shall be present at such hearing unless through counsel he or she waives the right to be present. G The request for hearing is DENIED because: G G DATE The above request does not allege any abuse or misuse of the admission procedure of § 12(b). Other (describe): JUDGE X (rev. 08/08) American LegalNet, Inc. www.FormsWorkFlow.com