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Petition For Involuntary Commitment Alcohol And Or Drug Dependency PC-803 - Connecticut

Petition For Involuntary Commitment Alcohol And Or Drug Dependency Form. This is a Connecticut form and can be used in Probate Statewide .
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PETITION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-803 REV. 7/13 Page 1 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] RECORDED (CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF DISTRICT NO. PETITIONER [Name, address and telephone number. Please also explain your relationship to the respondent.] SEX: M F Hereinafter referred to as the respondent. PERMANENT ADDRESS OF RESPONDENT PRESENT ADDRESS OF RESPONDENT [If confined for treatment, give name and address of treatment facility.] JURISDICTION BASED ON RESIDENCE DISTRICT WHERE RESPONDENT IS CONFINED FOR TREATMENT DISTRICT WHERE RESPONDENT IS AT THE TIME THE APPLICATION IS FILED [If the respondent is from out of state or residency is unknown.] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PETITIONER, SPOUSE [If not the petitioner], NEXT OF KIN [If none, so state], PARENT OR LEGAL GUARDIAN [If the respondent is a minor], ADMINISTRATOR OF THE TREATMENT FACILITY [If respondent has been committed for emergency treatment pursuant to C.G.S. § 17a-684, as amended], ADMINISTRATOR OF THE TREATMENT FACILITY TO WHICH THE RESPONDENT IS TO BE ADMITTED, and OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT[ Give names, addresses and relationships to respondent.] C.G.S. § 17a-685. THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not able to request or obtain an attorney. C.G.S. § 17a-685(c). Is Is not able to pay for the services of an attorney. [Submit Request Order/Waiver of Fees-Respondent, PC-184A.] The respondent's financial status is unknown to the petitioner. Continued PETITION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-803 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-803 REV. 7/13 Page 2 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] RECORDED (CONFIDENTIAL VOLUME): THE PETITIONER RESPECTFULLY ALLEGES that the named respondent resides in the town shown within this probate district or is now at the present address shown and that said respondent is an alcohol-dependent or drug-dependent person who is dangerous to self or dangerous to others when intoxicated OR gravely disabled as defined in C.G.S. § 17a-680. The petitioner is a person other than the certifying physician. The petitioner has filed or will file a certificate from a licensed physician who has examined the respondent within two days of the submission of this petition. A statement of the facts and information upon which the petitioner bases the allegations appears below, along with the names and addresses of physicians. [Use Second Sheet, PC-180, if more space is needed.] The petitioner is the certifying physician who has examined the respondent within two days of the submission of this petition. The petitioner has arranged for treatment in the facility named below, AND A STATEMENT TO THAT EFFECT FROM THE FACILITY IS ATTACHED HERETO. Name: PROPOSED Address: TREATMENT FACILITY WHEREFORE, THE PETITIONER REQUESTS that this court find that the respondent is an alcohol or drug-dependent person as set forth herein and that said respondent be ordered committed to a facility for treatment as provided by C.G.S. § 17a-685. The representations contained herein are made under the penalties of false statement. DATE: SIGNED ................................................................................................................ Petitioner [Type or print name.] ATTORNEY FOR PETITIONER [Name, address, telephone number and juris number ] Signature of attorney for petitioner ______________________________ [Attorney shall also file PC-183, Appearance of Attorney.] PETITION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-803 American LegalNet, Inc. www.FormsWorkFlow.com
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