To submit this form, ensure all sections are accurately completed and signed. You can email the completed form to the designated mental health facility, use the facility's fax number, or submit it through their online submission portal if available. For physical submissions, mail the form to the facility's address. Advice: Always keep a copy of the submitted form for your records and follow up with the facility to confirm receipt.

This form is effective as of September 25, 2013, and should be used in compliance with M.G.L. Chapter 123. Ensure to follow any updates provided by the Commonwealth of Massachusetts Department of Mental Health for the years 2024 and 2025.

The purpose of this form is to provide a standardized method for authorizing temporary involuntary hospitalization for individuals experiencing severe mental health crises. It ensures that all necessary legal and medical criteria are met to protect the individual and the community while complying with Massachusetts General Laws Chapter 123, Sections 12(a) and 12(b). This form facilitates proper documentation, evidence gathering, and certification by licensed mental health professionals to ensure that individuals receive the appropriate care and supervision. By using this form, healthcare providers can make informed decisions and take timely action to address urgent mental health situations. It serves as a critical tool for coordinating emergency admissions and safeguarding the well-being of individuals and the public.

• 1. Facility Name: The name of the facility to which the individual is being referred for hospitalization.
• 2. Individual Information: Personal details of the individual including name, address, city/town, state, social security number, date of birth, and sex.
• 3. Mental Illness Evidence: Documentation of the individual's mental illness, with detailed evidence of symptoms and behaviors supporting the need for hospitalization.
• 4. Likelihood of Serious Harm: Evidence that demonstrates the likelihood of the individual causing serious harm to themselves or others.
• 5. Applicant Certification: Certification by the applicant, including their professional designation and consultation details.
• 6. Designated Physician Authorization: Authorization by a designated physician including examination details, concurrence with the applicant's recommendation, and admission approval.

Failure to submit this form may result in the individual not receiving the necessary hospitalization and care. This can lead to significant risks to the individual's safety and well-being, as well as potential harm to others.

• Lack of Immediate Care: The individual may not receive the urgent mental health treatment they need.
• Safety Risks: Increased risk of the individual harming themselves or others due to lack of supervision.
• Legal Consequences: Potential legal issues for failing to comply with mandatory hospitalization procedures.

• 1. Immediate Risk: When an individual poses a substantial risk of physical harm to themselves or others.
• 2. Severe Mental Illness: When an individual exhibits symptoms of severe mental illness that impair their judgment and ability to function.
• 3. Emergency Situations: When a licensed mental health professional determines that immediate hospitalization is necessary.
• 4. Law Enforcement: When a police officer needs to place an individual under protective custody for mental health reasons.
• 5. Clinical Referrals: When a healthcare provider refers an individual to a facility for emergency psychiatric evaluation.