COMMONWEALTH OFMASSACHUSETTSDEPARTMENTOFMENTALHEALTH
NOTICEOFRIGHTS
(Parent or Guardian of aMinor)
Temporary Involuntary Hospitalization
M.G.L.Chapter123, Section12(b)
Yourchildhas beenadmittedto thisfacility underM.G.L. c. 123, s. 12(b)fora periodof uptothree(3)business days. By theend of the third (3rd)business day, if theSuperintendent orotherheadof the facility decides thatyourchild's releasewouldcreatea likelihood of serious harmtoyourchildorothers by reasonof mentalillness, heorshemayfilea petition foryourchild'scivilcommitment tothe facility foraperiodof upto sixmonths. If a petition isfiled, the District Court willbeginthehearingwithin five (5)businessdays, not including Saturday,Sunday orholidays, duringwhichtimeyour childwillhavetoremaininthe facility.
At yourrequest, wewillnotify theCommitteeforPublicCounselServices(CPCS)of youandyourchild’snameandlocation. CPCSwillthenappointanattorney tomeetwithyouandyourchild. Wouldyoulikeus tocontactCPCSonyourchild's behalf at thistime? Yes
No
If yousay Noandchangeyourmindlater, wewillnotify CPCSforyouandyourchildat that time.
If youhavereasonto believe that your child’sadmissionto thisfacility underM.G.L. c. 123, s. 12(b) is theresult of anabuse ormisuseof theadmissions process, youmay request, onyourownorthroughcounsel, anemergency hearinginthe District Court inwhosejurisdiction
thisfacilityis located. If youwishtofilesucharequest, the facilitywillprovideyouwiththeappropriateform.
I havereceivedandread this Notice:
Parent/Guardian’sNameDate
Patient Name
Staffwitness signatureDate
Form 12(b)rights-302G EffectiveDecember, 2016