Form AA-5 "Application for and Authorization of Temporary Involuntary Hospitalization" - Massachusetts

What Is Form AA-5?

This is a legal form that was released by the Massachusetts Department of Mental Health - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form AA-5 "Application for and Authorization of Temporary Involuntary Hospitalization" - Massachusetts

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COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF MENTAL HEALTH
APPLICATION FOR AN AUTHORIZATION OF TEMPORARY INVOLUNTARY HOSPITALIZATION
M.G.L. Chapter 123, Sections 12 (a) and 12 (b)
Application Pursuant to 12 (a)
): ________________________________________________
1). Application to (Facility name
2). I hereby apply for admission of (name of individual): _______________________________________
Address:_________________________City/Town_________________________State_____________
Social Security Number: __________________ Date of Birth: _____________ Sex: M
F
to the facility named above pursuant to M.G.L. c. 123, s. 12 (a). I hereby authorize transport and the use of restraint of
the person named above but only if necessary for the safety of the person being transported or of others who are likely
to come into contact with him or her. M.G.L. Chapter 123, s. 21.
1
Based on my examination
, it is my opinion that the person requires hospitalization at the above named facility so as to
avoid the likelihood of serious harm by reason of mental illness. Evidence supporting my opinion includes:
A). Mental Illness: For purposes of admission to an inpatient facility under Section 12, “Mental Illness” means a
substantial disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior,
capacity to recognize reality or ability to meet the ordinary demands of life. Symptoms caused solely by alcohol or drug
intake, organic brain damage or intellectual disability do not constitute a serious mental illness. Specify evidence
including behavior and symptoms:
_______________________________________________________________________________________
_______________________________________________________________________________________
B). Likelihood of Serious Harm (check all categories that apply):
_____ (1) Substantial risk of physical harm to the person himself/herself as manifested by evidence of threats of, or
attempts at suicide or serious bodily harm; and/or
_____ (2) Substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent
behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to
them; and/or
_____ (3) Very substantial risk of physical impairment or injury to the person himself/herself as manifested by evidence
that such person’s judgment is so affected that he/she is unable to protect himself/herself in the community and
the reasonable provision of his/her protection is not available in the community.
Specify evidence including behavior and symptoms:______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3). Applicant Certification (check all applicable boxes)
a. I am a:
Licensed Physician or Nurse Practitioner (GL. Ch 112 §80i)
Qualified (
) Psychologist
i.e. Licensed
Qualified
) Psychiatric Nurse Mental Health Clinical Specialist
(i.e. Licensed and Certified
Police Officer
Licensed Independent Clinical Social Worker (LICSW)
b. I have
I have not
personally examined this person. If not, why? ________________________________
______________________________________________________________________________________________
c.
I have consulted with either the receiving facility or emergency screening program.
d.
I have not so consulted because__________________________________________________
____________________________________________________________________________________
Applicant’s name (not patient):
(print)__________________________________________Phone:_______________________________
Address:_____________________________________City/Town_______________________State____
________
Applicant’s signature:_____________________________ Date: _________________ Time:
hospitalization.
NOTE: Parts 1) through 3), above, must be completed to apply for involuntary
Form AA-5
See Reverse for Section 12(b)
Effective – September 25, 2013
1
If an examination is not possible because of the emergency nature of the case and because of the refusal of the person to consent to such
examination, the physician, qualified psychologist, qualified psychiatric nurse mental health clinical specialist or licensed independent clinical
social worker on the basis of the facts and circumstances may determine that hospitalization is necessary and may apply therefore. G.L.
c.123 s.12(a)
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF MENTAL HEALTH
APPLICATION FOR AN AUTHORIZATION OF TEMPORARY INVOLUNTARY HOSPITALIZATION
M.G.L. Chapter 123, Sections 12 (a) and 12 (b)
Application Pursuant to 12 (a)
): ________________________________________________
1). Application to (Facility name
2). I hereby apply for admission of (name of individual): _______________________________________
Address:_________________________City/Town_________________________State_____________
Social Security Number: __________________ Date of Birth: _____________ Sex: M
F
to the facility named above pursuant to M.G.L. c. 123, s. 12 (a). I hereby authorize transport and the use of restraint of
the person named above but only if necessary for the safety of the person being transported or of others who are likely
to come into contact with him or her. M.G.L. Chapter 123, s. 21.
1
Based on my examination
, it is my opinion that the person requires hospitalization at the above named facility so as to
avoid the likelihood of serious harm by reason of mental illness. Evidence supporting my opinion includes:
A). Mental Illness: For purposes of admission to an inpatient facility under Section 12, “Mental Illness” means a
substantial disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior,
capacity to recognize reality or ability to meet the ordinary demands of life. Symptoms caused solely by alcohol or drug
intake, organic brain damage or intellectual disability do not constitute a serious mental illness. Specify evidence
including behavior and symptoms:
_______________________________________________________________________________________
_______________________________________________________________________________________
B). Likelihood of Serious Harm (check all categories that apply):
_____ (1) Substantial risk of physical harm to the person himself/herself as manifested by evidence of threats of, or
attempts at suicide or serious bodily harm; and/or
_____ (2) Substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent
behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to
them; and/or
_____ (3) Very substantial risk of physical impairment or injury to the person himself/herself as manifested by evidence
that such person’s judgment is so affected that he/she is unable to protect himself/herself in the community and
the reasonable provision of his/her protection is not available in the community.
Specify evidence including behavior and symptoms:______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3). Applicant Certification (check all applicable boxes)
a. I am a:
Licensed Physician or Nurse Practitioner (GL. Ch 112 §80i)
Qualified (
) Psychologist
i.e. Licensed
Qualified
) Psychiatric Nurse Mental Health Clinical Specialist
(i.e. Licensed and Certified
Police Officer
Licensed Independent Clinical Social Worker (LICSW)
b. I have
I have not
personally examined this person. If not, why? ________________________________
______________________________________________________________________________________________
c.
I have consulted with either the receiving facility or emergency screening program.
d.
I have not so consulted because__________________________________________________
____________________________________________________________________________________
Applicant’s name (not patient):
(print)__________________________________________Phone:_______________________________
Address:_____________________________________City/Town_______________________State____
________
Applicant’s signature:_____________________________ Date: _________________ Time:
hospitalization.
NOTE: Parts 1) through 3), above, must be completed to apply for involuntary
Form AA-5
See Reverse for Section 12(b)
Effective – September 25, 2013
1
If an examination is not possible because of the emergency nature of the case and because of the refusal of the person to consent to such
examination, the physician, qualified psychologist, qualified psychiatric nurse mental health clinical specialist or licensed independent clinical
social worker on the basis of the facts and circumstances may determine that hospitalization is necessary and may apply therefore. G.L.
c.123 s.12(a)
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF MENTAL HEALTH
Authorization Pursuant to Section 12 (b)
Designated Physician* Authorization :
(NOTE: Boxes A. through G., below, must be checked to authorize a Section 12(b) involuntary
admission to a facility.)
A.
I am a designated physician* of the aforementioned facility with authority to
authorize admissions under Section 12 (b).
B.
I have personally examined this person
within 2 hours of his/her arrival at the facility
more than 2 hours after his/her arrival at the facility due to the fact that I was engaged in
an emergency situation.** The emergency situation was:
and I examined the patient at
am/pm.
C.
This person does not require emergency or inpatient medical or surgical care.
D.
I have offered this person an application for Care and Treatment on a Conditional Voluntary
Basis and the person:
(one of the two boxes below must be checked to proceed with a Section 12(b) authorization)
refused to sign, or
the application was rejected (the reasons why the application was rejected must be
stated on the application and the rejected application shall become part of this
person’s medical record at the facility).
Note:
104 CMR 27.07 (1) requires that the patient be offered an opportunity to change to
conditional voluntary status again within three days of admission.
E.
I concur with the applicant’s recommendation and have completed a psychiatric
examination to support this conclusion. Alternatively, I am the applicant, I have
personally examined this person, and have completed sections 1), 2), 2A) and 2B)
on the opposite side of this form.
F.
In my opinion, at the present time there is no less restrictive placement that is appropriate for
this person to which he or she is willing to go.
G.
I authorize this person’s admission.
H.
I reject this application for admission for the following reasons:
Designated Physician’s Name (print):
Phone:
Address:
Designated Physician’s Signature:
Date: ___________________________________
Time: _____________________________
*
A physician who meets the criteria in 104 CMR 33.03
** See 104 CMR 27.07 (2)
Form AA-5
Effective – September 25, 2013
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