Release Of Information Form Mental Health Template In Massachusetts
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Individuals (such as family members) can ask the court to order an emergency mental health commitment, called Section 12 (e) or a commitment for treatment of alcohol or substance use disorder, called a Section 35, by speaking to a clerk in the court.
LAWS ANN. ch. 123, § 12(e). Any person may make an application to a district court justice or a justice of the juvenile court department for a 3-day commitment to a facility of a person with a mental illness if the failure to confine said person would cause a likelihood of serious harm.
Visit your local district court and inquire about an MGL c 123 sec 12 3-day commitment to a hospital for a mental health evaluation. This is for people in crisis and who may be a danger to themselves or others.
I hereby authorize use or disclosure of protected health information about me as described below. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
5250: The mental health facility may seek an additional 14-day involuntary hold called a “5250” if the person is still deemed to be in a mental health crisis.
Section 12E: Drug dependent minors; consent to medical care; liability for payment; records.
Youths 16 or older may commit themselves to a mental health facility. See G.L. c. 123, §10; 104 CMR 27.06(1); 110 CMR 11.16(2).
