Connecticut > Statewide > Probate

Psychologists Report Placement Of Person With Intellectual Disability PC-772 - Connecticut

Psychologists Report Placement Of Person With Intellectual Disability Form. This is a Connecticut form and can be used in Probate Statewide .
 Fillable pdf Last Modified 5/27/2014
Get this form for FREE as a print-only pdf

PSYCHOLOGIST'S REPORT/ PLACEMENT OF PERSON WITH INTELLECTUAL DISABILITY PC-772 REV. 10/11 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink. ] TO: COURT OF PROBATE, IN THE MATTER OF Hereinafter referred to as the respondent. DISTRICT NO. RESPONDENT'S DATE OF BIRTH PRESENT ADDRESS OF RESPONDENT [If institutionalized, give PETITIONER [Name, address, zip code, and telephone number] name and address of institution.] PSYCHOLOGIST SELECTED BY THE COURT [Name, address, zip code, and telephone number] CONN. PSYCHOLOGIST'S LIC. NO. DATE OF EXAM [Month, day, year] PSYCHOLOGIST SELECTED BY RESPONDENT, if any [Name, address, zip code, and telephone number] CONN. PSYCHOLOGIST'S LIC. NO. DATE OF EXAM [Month, day, year] ATTORNEY(S) OF RECORD [Name, address, zip code, telephone number, and juris number. ] Is the respondent a person with intellectual disability as defined in C.G.S. § 1-1g? questions. You must give reasons for your opinions. Yes No LL of the following Please explain the results of any psychological assessment given within the past year. [Identify all standard assessments used.] What were the results of your interview with, or your observation of, the respondent? Please provide an evaluation of the adaptive behavior of the respondent, including a statement of the respondent's needs. ............................................................................................................ Psychologist: NOTE TO PSYCHOLOGIST: This form should be returned to the Court and duplicate copies filed with the Commissioner of Developmental Services and all attorneys of record at least five (5) days prior to the hearing. The following is the statutory requirement for the examination of the respondent [C.G.S.§17a-274(f)]. "Such report shall include a statement as to whether the respondent is a person with intellectual disability and an explanation of how the determination was reached. The explanation shall include the results of a psychological assessment within the past year, an interview or observation of the respondent, and an evaluation of adaptive behavior. Such report shall include a statement of the respondent's needs. Duplicate copies of the report shall be filed with the Commissioner of Developmental Services and all attorneys of record at least five days prior to the hearing. The Court shall order the psychologist to appear for cross-examination at the request of the respondent if the respondent makes such request at least three days before the hearing." PSYCHOLOGIST'S REPORT/ PLACEMENT OF PERSON WITH INTELLECTUAL DISABILITY PC-772 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. probate
  2. order to show cause
  3. motion to dismiss
  4. Notice of Appearance
  5. motion
  6. subpoena duces tecum
  7. termination of parental rights
  8. order
  9. Summon
  10. subpoena

Bookmark and Share