States vary considerably in their approach to handling the mental health treatment of individuals who are determined to be Not Guilty by Reason of Insanity (NGRI). In New Hampshire, the process is a by-product of both historical and legal precedent. We endeavored to elucidate and understand the current processes by which individuals deemed to be NGRI are cared for in the mental health system. We interviewed key stakeholders and individuals directly involved. We reviewed the aggregate summary data of all known NGRI patients in the state and completed a literature search for studies and descriptions of the NGRI process in other states. The NGRI process in New Hampshire is historically-driven and designed to protect both the general public from potential future harm of individuals who are NGRI as well as allow conservative advancement of privileges in a step-wise manner.