Psychologists Evaluation {PC-372}

PC-372 - PSYCHOLOGIST’S EVALUATION/CONSERVATORSHIP OF PERSON WITH INTELLECTUAL DISABILITY. A psychologist may be requested to complete this form in connection with an involuntary proceeding for the appointment of a conservator of the person or estate for a respondent with intellectual disability as defined by C.G.S. section 1-1 g or review of a conservatorship for an adult with intellectual disability previously established by the Probate Court. “Intellectual disability” is defined in C.G.S. section 1-1g as “a significant limitation in intellectual functioning existing concurrently with deficits in adaptive behavior that originated during the developmental period before eighteen years of age.” A “significant limitation in intellectual functioning” is defined as an intelligence quotient (“IQ”) more than two standard deviations below the mean, as measured by standard tests of general intellectual functioning. This means that the person’s IQ must be 69 or less. The named psychologist must be licensed to practice in Connecticut and must have personallyexamined the patient on the Date of Examination. Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. www.FormsWorkflow.com