psychiatric unit within a public health hospital; a Department of Mental Health-licensed psychiatric hospital; a Department of Mental Health-licensed psychiatric unit within a general hospital; or a Department of Mental Health-licensed secure intensive residential treatment program for adolescents.
Effective April 4, 2008
NOTE: Restraint may not be used in the course of transport unless necessary for the safety of the individual being transported or of others who are likely to come into contact with him or her. M.G.L. Chapter 123, Section 21 1) is an individual who has been hospitalized for mental illness pursuant to M.G.L. c. 123 and who requires transport from
(name of facility or facility campus)
2) I authorize the transport with the use of restraint only if necessary according to the standard set forth in 104 CMR 27.08 (9), of this individual from the facility (or facility campus) identified in paragraph 1) to
and the return trip (check, where applicable)
for the following purpose:
transfer to another facility pursuant to M.G.L. c. 123, §3: movement among separate campuses of a single facility evaluation and/or treatment at a medical facility or office; attendance at court proceedings;
transfer to or from another state pursuant to the Interstate Compact on
Mental Health, M.G.L. c. 123 App. §§1-1 through 1-4
other (requires approval of facility director or designee)
3) I am an authorized physician or an authorized staff person at the facility identified in paragraph 1).
Physician (or staff person) Name: (print) Facility Name: Address: City/TownState Phone: Signature: Date: A copy of this form shall accompany the individual during transport.