Fill and Sign the Petition for Commitment of Form

JV-096 (01/02/2013) PETITION FOR COMMITMENT OF ALCOHOLIC OR SUBSTANCE ABUSER G.L. c. 123, § 35 DOCKET NUMBER Trial Court of Massachusetts Juvenile Court Department In the Matter of: NAME OF RESPONDENT DOB OR AGE GENDER Male Female DIVISION The undersigned petitioner hereby applies to this court for an order com\�mitting the respondent named above for inpatient care and treatment for alcoholism and/or substance abuse for a\� period not to exceed 90 days under the provisions of G.L. c. 123, § 35. The petitioner has reason to believe that there is a likelihood of serio\�us harm as a result of the respondent’s chronically or habitually consuming or ingesting alcoholic beverages and\�/or controlled substances or intentionally inhaling toxic vapors to the extent that such use substantially injures \�the respondent’s health or substantially interferes with the respondent’s social or economic functioning, or t\�hat the respondent has lost the power of self- control over use of such beverages and/or substances. WARRANT OF APPREHENSION The petitioner also requests the court to issue a Warrant of Appreh\�ension. The respondent is unlikely to appear for an examination and any further delay in the proceedings would\� present an immediate danger to the physical well-being of the respondent. DATE SIGNATURE OF PETITIONER x RESPONDENT INFORMATION PETITIONER'S RELATIONSHIP TO RESPONDENT PRINT NAME AND TITLE ADDRESS OF PETITIONER ADDRESS OF RESPONDENT Complete this Section Only if the Respondent is a Child Who is the child's legal custodian? NAME AND ADDRESS OF LEGAL CUSTODIAN IF OTHER THAN PETITIONER TELEPHONE NUMBER: CELL PHONE NUMBER: CELL PHONE NUMBER: TELEPHONE NUMBER: CELL PHONE NUMBER: TELEPHONE NUMBER: JV-096 (01/02/2013) INSTRUCTIONS FOR COMMITMENT OF ALCOHOLIC OR SUBSTANCE ABUSERFOR PURPOSES OF INPATIENT CARE DEFINITION OF“ALCOHOLIC”: For the purposes of G. L. c. 123, § 35, "alcoholic'' shall mean a p\�erson who chronically or habitually consumes alcoholic beverages to the extent\� that (1) such use substantially injures his health or substantially interferes with his social or econom\�ic functioning, or (2) he has lost the power of self-control over the use of such beverages. DEFINITION OF“SUBSTANCE ABUSER”: For the purposes of G. L. c. 123, § 35,"substance abuser'' shall mean a person who chronically or habitually consumes or ingests controll\�ed substances or who intentionally inhales toxic vapors to the extent that: (i) such use substantially in\�jures his health or substantially interferes with his social or economic functioning; or (ii) he has lost the power\� of self-control over the use of such controlled substances or toxic vapors. STATUTORY BASIS FOR COMMITMENT: Any police officer, physician, spouse, blood relative, guardian or court official may petition in writing any district court or any divi\�sion of the juvenile court department for an order of commitment of a person whom he has reason to believe is an alco\�holic or substance abuser. Upon receipt of a petition for an order of commitment of a person and any swo\�rn statements the court may request from the petitioner, the court shall immediately schedule a hear\�ing on the petition and shall cause a summons and a copy of the application to be served upon the person in th\�e manner provided by section twenty-five of chapter two hundred and seventy-six. In the event of the\� person's failure to appear at the time summoned, the court may issue a warrant for the person's arrest. Upon pr\�esentation of such a petition, if there are reasonable grounds to believe that such person will not appear\� and that any further delay in the proceedings would present an immediate danger to the physical well-being\� of the respondent, said court may issue a warrant for the apprehension and appearance of such person b\�efore it. No arrest shall be made on such warrant unless the person may be presented immediately befo\�re a judge of the district court. The person shall have the right to be represented by legal counsel and m\�ay present independent expert or other testimony. If the court finds the person indigent, it shall immed\�iately appoint counsel. The court shall order examination by a qualified physician or a qualified psychologist. If, after a hearing and based upon competent testimony, which shall incl\�ude, but not be limited to, medical testimony, the court finds that such person is an alcoholic or substance\� abuser and there is a likelihood of serious harm as a result of the person's alcoholism or substance abuse, \�the court may order such person to be committed for a period not to exceed 90 days, followed by the availab\�ility of case management services provided by the department of public health for up to 1 year; provided, \�however, that a review of the necessity of the commitment shall take place by the superintendent on da\�ys 30, 45, 60 and 75 as long as the commitment continues. A person so committed may be released prior t\�o the expiration of the period of commitment upon written determination by the superintendent that release\� of that person will not result in a likelihood of serious harm. Such commitment shall be for the purpose of\� inpatient care in public or private facilities approved by the department of public health under chapter 111\�B for the care and treatment of alcoholism or substance abuse. The person may be committed to the Massa\�chusetts correctional institution at Bridgewater, if a male, or at Framingham, if a female, if there are n\�ot suitable facilities available under said chapter 111B; provided, however, that the person so committed shall\� be housed and treated separately from convicted criminals. Such person shall, upon release, be encourage\�d to consent to further treatment and shall be allowed voluntarily to remain in the facility for such purp\�ose.