Massachusetts' AA-5, commonly called a Section 12 or pink paper, carries both halves of a temporary involuntary hospitalization under M.G.L. c. 123. On Side 1, a clinician who has examined the person applies under Section 12(a), giving evidence of mental illness and which likelihood-of-serious-harm categories apply. On Side 2, the receiving facility's designated clinician authorizes or rejects admission under Section 12(b).
A Massachusetts-licensed physician, licensed psychologist, advanced practice registered nurse or LICSW completes Side 1, parts 1 to 3; the form also has a police officer box. Side 2 is signed by the facility's designated clinician, a physician or qualified APRN authorized under 104 CMR 33.00.
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Application for an Authorization of Temporary Involuntary Hospitalization
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A Massachusetts-licensed physician, licensed psychologist, advanced practice registered nurse or licensed independent clinical social worker. They normally examine the person first. If an examination is impossible because of the emergency and the person's refusal, the clinician may decide on the facts and circumstances that hospitalization is necessary and still apply.
The designated clinician examines the person, confirms they do not need emergency medical or surgical care, offers a conditional voluntary application, and checks that no less restrictive placement is appropriate. All of boxes A to G must be checked to authorize admission; box H records a rejection with reasons. The patient must be offered conditional voluntary status again within three days.
Yes. The Department of Mental Health posts the AA-5 in Spanish, Haitian Creole, Portuguese, traditional and simplified Chinese, and Vietnamese on its civil commitment and hospital admissions forms page, alongside the related notice-of-rights, conditional voluntary and transport forms such as BB-303 and CV-302G-12b.