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Petition For Involuntary Commitment Of Person With Psychiatric Disabilities PC-801 - Connecticut

Petition For Involuntary Commitment Of Person With Psychiatric Disabilities Form. This is a Connecticut form and can be used in Probate Statewide .
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PETITION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 REV. 7 /13 Page 1 TO: COURT OF PROBATE, IN THE MATTER OF STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] RECORDED (CONFIDENTIAL VOLUME): DISTRICT NO. RESPONDENT'S SOCIAL SECURITY NUMBER SEX M F RESPONDENT'S DATE OF BIRTH RELATIONSHIP OF PETITIONER TO RESPONDENT Hereinafter referred to as the respondent. PETITIONER [Name, address and telephone number] PERMANENT ADDRESS OF RESPONDENT PRESENT ADDRESS OF RESPONDENT [If hospitalized for psychiatric disabilities, give name and address of hospital.] JURISDICTION BASED ON RESIDENCE DISTRICT WHERE RESPONDENT IS HOSPITALIZED FOR PSYCHIATRIC DISABILITIES DISTRICT WHERE RESPONDENT IS AT THE TIME THE PETITION 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], CLOSEST RELATIVES [If none, so state], and INTERESTED PARTIES[e.g. conservators, guardians, etc. Give names, addresses and relationships to respondent.] C.G.S. §17a-498. THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is Is not able to request or obtain an attorney. C.G.S. § 17a-498(b). 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. THE PETITIONER RESPECTFULLY ALLEGES in accordance with C.G.S.§ 17a-497 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 has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled in the following respects:[Describe condition and/or behavior of respondent to support this allegation, including diagnosis, if any, and relevant history. Continue on next page, as needed.] PETITION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 REV. 7 /13 Page 2 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] RECORDED (CONFIDENTIAL VOLUME): IF THE RESPONDENT IS HOSPITALIZED FOR PSYCHIATRIC DISABILITIES, CHECK THE APPROPRIATE BOX(ES): Involuntary Admission [C.G.S.§ 17a-498(c)]. Any patient hospitalized pursuant to an order of a judge of the probate court after an appropriate hearing. Emergency Commitment [C.G.S. § 17a-502(a)]. A patient hospitalized for emergency diagnosis, observation or treatment upon certification of a qualified physician. Voluntary Admission [C.G.S. § 17a-506(a)]. Any patient sixteen years of age or older who applies in writing to, and is admitted to, a hospital for psychiatric disabilities as a person with psychiatric disabilities. Explain: Informal Admission [C.G.S. § 17a-507]. A patient admitted to any general hospital having psychiatric facilities for observation and treatment without formal or written application. The Superior Court has found that the respondent is not competent to stand trial. By order of the Superior Court, the respondent has been placed with the Commissioner of Mental Health and Addicion Services for the purposes of civil commitment [C.G.S. §54-56d] The undersigned, if the hospital superintendent or his/her authorized representative, further states that voluntary status was offered to the respondent within twenty-four hours of the time of this application and was refused. [C.G.S. §17a-498(e).] WHEREFORE, THE PETITIONER REQUESTS that this court make an order for the above-named respondent's confinement to a hospital for psychiatric disabilities. The representations contained herein are made under the penalties of false statement. Date: .................................................................................................. Petitioner [Type or print name.] Name PROPOSED HOSPITAL FOR PSYCHIATRIC DISABILITIES Address ATTORNEY FOR PETITIONER [Name, address, telephone number and juris number] Attorney shall file an Appearance of Attorney, Form PC-183. PETITION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 American LegalNet, Inc. www.FormsWorkFlow.com
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