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Petition For Involuntary Recommitment Alcohol And Or Drug Dependency PC-804 - Connecticut

Petition For Involuntary Recommitment 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 RECOMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-804 Page 1 REV. 7/13 TO: COURT OF PROBATE, IN THE MATTER OF STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] RECORDED (CONFIDENTIAL VOLUME): DISTRICT NO. SEX: M F PETITIONER [Name, address and telephone number.] Administrator of Hereinafter referred to as the respondent. PERMANENT ADDRESS OF RESPONDENT an Inpatient Outpatient Facility 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 PETITION IS FILED [If the respondent is from out of state or residency is unknown. ] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PETITIONER, SPOUSE, NEXT OF KIN [If none, so state], PARENT OR LEGAL GUARDIAN [If the respondent is a minor], ADMINISTRATOR OF THE TREATMENT FACILITY TO WHICH THE RESPONDENT IS TO BE ADMITTED[If different from petitioner], and OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT[Give names, addresses and relationships to respondent.] C.G.S. § 17a-685 Continued PETITION FOR INVOLUNTARY RECOMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-804 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR INVOLUNTARY STATE OF CONNECTICUT RECOMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY COURT OF PROBATE PC-804 Page 2 REV. 7/13 [Type or print in ink.] THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not able to request or obtain an attorney. C.G.S. § 17a-498(b). Is RECORDED (CONFIDENTIAL VOLUME): 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 FURTHER REPRESENTS THAT said respondent was committed to: a facility for the treatment of alcohol and/or drug dependency, by order of this court dated 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: The respondent is an alcohol-dependent person drug-dependent person who needs further inpatient treatment and is likely to become dangerous to himself or dangerous to others when intoxicated or likely to become gravely disabled and is likely to benefit from such treatment. The respondent is an alcohol-dependent person drug-dependent person who is not successfully participating in the outpatient program and is likely to become dangerous to himself or dangerous to others when intoxicated or likely to become gravely disabled and is likely to benefit from such treatment. The petitioner has arranged for treatment in the facility named below, AND A STATEMENT TO THAT EFFECT FROM SAID FACILITY IS ATTACHED HERETO. Name PROPOSED TREATMENT Address FACILITY WHEREFORE,THE PETITIONER REQUESTS that this court find that the respondent is an alcohol-dependent or drug-dependent person as set forth herein and that said respondent be ordered recommitted to a treatment 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 RECOMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-804 American LegalNet, Inc. www.FormsWorkFlow.com
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