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Conservators Report Placement Or Request For Hearing On Placement PC-371A - Connecticut
| Conservators Report Placement Or Request For Hearing On Placement Form. This is a Connecticut form and can be used in Probate Statewide . |
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CONSERVATOR'S REPORT/PLACEMENT OR REQUEST FOR HEARING ON PLACEMENT PC-371A NEW 10/05 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] [Use additional sheets if more space is required.] PLEASE SEE IMPORTANT NOTICE ON REVERSE SIDE. DISTRICT NO. TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF [Name, address, zip code, and date of birth] PRESENT ADDRESS OF WARD [If institutionalized, give name and address of institution.] HEREINAFTER REFERRED TO AS THE "WARD" PRESENT TREATING PHYSICIAN [Name, address, and zip code. ] CONSERVATOR OF THE PERSON [Name, address, zip code, and telephone number. ] This conservator's report is being filed for the following reason:[C.G.S. ยงยง45a-654(g) and 45a-656(c)] Request for hearing regarding placement of the ward in an institution for long-term care. [List name and address of proposed institution.] Placement of the ward in an institution for long-term care has taken place, and this report is being filed within five days of placement. List the reasons for placement. List the community resources, if any, that have been considered to avoid placement. [For example, resources provided by Area Agencies on Aging, the Department of Social Services, and the Office of Protection and Advocacy for Persons with Disabilities.] List the reason(s) why the ward's physical, mental, and psychosocial needs cannot be met in a less restrictive and more integrated setting. This section is to be completed for placements that took place prior to the filing of the report. Was the placement a result of the ward's discharge from a hospital? YES NO If "YES," please provide a statement about the discharge from the hospital, including the hospital's name and address and date of discharge: If "NO," please provide a description of the irreparable injury that the placement averted: I hereby certify that I have given notice of the placement and a copy of this report to the ward and to the Court-appointed attorney and to any other interested parties as determined by the Court. ....................................................................................... Conservator: Dated at: ,Connecticut, on [Month, Day, Year] CONSERVATOR'S REPORT/PLACEMENT OR REQUEST FOR HEARING ON PLACEMENT PC-371A American LegalNet, Inc. www.USCourtForms.com IMPORTANT NOTICE To THE WARD (the person under conservatorship) and to ANY OTHER PERSON determined by the Court to have an interest in this matter. You have the right to request that the Court hold a hearing on this report and placement. You can exercise this right by advising the Court, in writing, of your desire for a hearing by returning a copy of the form printed below. As a result of such hearing, the Court may determine that the ward's physical, mental, and psychosocial needs can be met in a less restrictive and more integrated setting within the limitations of the resources available to the ward, either through the ward's own estate or through public or private assistance. If such a determination is made, the Court shall order that the ward be placed and maintained in such a setting. Dated at: ,Connecticut, on [Month, Day, Year] Fax number: Court telephone number: The Court's mailing address is: REQUEST FOR FORMAL HEARING IN THE MATTER OF: I hereby request a hearing regarding the report and placement of the ward named on the first page and understand that I will receive advance written notice of the time and place of the hearing. ............................. Date Signature .............................................................................. .......................................................................................... [Please type or print name here.] If the address on the envelope you received was incorrect in any way, please correct it below. CONSERVATOR'S REPORT/PLACEMENT OR REQUEST FOR HEARING ON PLACEMENT PC-371A (Reverse) NEW 10/05 American LegalNet, Inc. www.USCourtForms.com
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