FORMS CONCERNING ADMISSION TO THE HOSPITAL.

PETITION.

[The applicant must answer in writing the printed interrogations accompanying this

blank.]

To the Honorable the Judge of the Probate Court, in and for the County

of

that

of

is an insane person, and a proper subject for the treatment

and custody of the Worcester Lunatic Hospital.

Wherefore, he prays that said

may be committed to the said Worcester Lunatic Hospital according to law.

that notice has been given to me of the intention to present the foregoing complaint and application.

A. D. 187.

To the Honorable the Judge of the Probate Court, in and for the County of

The subscriber, having made application to your Honor for the commitment of to the Worcester Lunatic Hospital, as a lunatic, now presents the following statement, in answer to interrogatories:What is the age of the lunatic? Ans.

Character-whether mild, violent or dangerous? Ans.

Homicidal or suicidal? Ans.

Paralytic or epileptic? Ans.

Previous existence of insanity in the lunatic? Ans.

Previous or present insanity in any of the family? Ans.

Habits in regard to temperance? Ans.

Whether he has been in any lunatic hospital; if so, what one, when, and how long? Ans.

(If a woman.) Has she ever borne any children? Ans.

(If a woman.) How long since the birth of her last child? Ans. Name and post-office address of some of the nearest relatives or friends? Ans.

What facts show whether he has or has not a settlement, and where, if anywhere, in this State? Ans.

[For the law relating to settlement, see Gen. Stat., chap. 69.]

application, within one week prior to the date hereof, certify that the said is insane, and a proper subject for the

treatment and custody of the Worcester Lunatic Hospital.

given by said applicant to one of the selectmen of where said

application, and said

resides, of h

intention to make said having been duly notified of

the time and place appointed for hearing, it appears, upon a full hearing, that said is an insane person, and a proper subject for the treatment and custody of the Worcester Lunatic Hospital. Wherefore it is ordered that said

to the said Worcester Lunatic Hospital.

be committed

Judge of Probate Court.

in behalf of the inhabitants of said town, do Treasurer of said hospital, to pay

hereby promise him, or his successor in said office, the rate of board which may, from time to time, be determined by the Trustees of said hospital, for said patient, so long as he shall continue a boarder in said hospital, with such extra charges as may be occasioned by h requiring more than ordinary care and attention, to provide for h suitable, and to pay for all such necessary articles of clothing as shall be procured for h by the Steward of the hospital, and to remove h from said hospital whenever the room occupied by h shall be required by a class of patients having preference by law, or in the opinion of the Superintendent, to be received in said hospital. Also, to pay not exceeding fifty dollars for all damages he may do to the furniture and other property of said hospital, and for reasonable charges in case of elopement, and funeral charges in case of death. Payment to be made quarterly, and at the time of removal, with interest on each bill from and after the time it becomes due. Witness our hands this

day of

to pay him or his successor in said office the rate of board which may, from time to time, be determined by the Trustees of said hospital, for said patient, so long as he shall continue a boarder in said hospital, with such extra charges as may be occasioned by h requiring more than ordinary care and attention; to provide for h suitable clothing, and to pay for all such necessary articles of clothing as shall be procured for h by the Steward of the hospital, and to remove h from said hospital whenever the room occupied by h shall be required for a class of patients having preference by law, or, in the opinion of the Superintendent, to be received into said hospital. Also to pay not exceeding fifty dollars for all damages he

may do the furniture and other property of said hospital, and for reasonable charges in case of elopement, and funeral charges in case of death. Payment to be made quarterly, and at the time of removal, with interest on each bill from and after the time it becomes due.

Patients will be received into the hospital at any time, if the following conditions are complied with :

:

If the patient is in indigent circumstances, and has no settlement in any town in the Commonwealth, the Probate Court, or, if in the city of Boston, the Superior Court, will issue a warrant for the commitment of the patient to the hospital. The State will then pay the cost of support, and the county from which the patient is sent will pay the expenses of the commitment.

If the patient is in indigent circumstances, and has a settlement in any town in the Commonwealth, the Overseers of the Poor of that town may give a bond for the support of the patient. Or, when this is inconvenient, an application may be made to the Probate Court of the county where the patient resides, and a warrant will be issued for the commitment of the patient to the hospital, and the town will be held responsible for the support of the patient.

In all other cases, a bond from responsible persons, as principal and surety, will be required for the expenses of the patient while in the hospital.

In all cases, before admission to the hospital, two physicians, one of whom shall be the family physician, must certify that the patient is insane. All necessary clothing must be supplied by the friends of the patient. Clothing will be supplied at the hospital, if desirable, and charged in the bills of cost.

Damages done to the furniture and other property to the amount of fifty dollars may also be charged.

Reasonable charges will be made in case of elopement, and funeral charge in case of death.

All bills are collected by the Treasurer quarterly, or interest charged on the same after becoming due.

Bills become due on the first of January, April, July and October, and when the patient leaves the hospital.

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