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Physicians Evaluation Conservatorship PC-370 - Connecticut
| Physicians Evaluation Conservatorship Form. This is a Connecticut form and can be used in Probate Statewide . |
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PHYSICIAN'S EVALUATION CONSERVATORSHIP PC-370 REV. 10/04 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink]. RECORDED (CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. With the knowledge that the contents of this report will be used as evidence in a judicial proceeding that may result in the loss of some or all of the respondent's/ward's rights, the undersigned physician states that he or she has personally examined the respondent/ward and makes the following report: RESPONDENT/WARD [Name] PHYSICIAN [Name, address, zip code, and telephone no.] PRACTICING PSYCHIATRIST YES NO CONNECTICUT MEDICAL LICENSE NO. DATE OF EXAMINATION [Month, day, year] YES NO IF YES, A. IS THE RESPONDENT/WARD'S CAPACITY TO MAKE DECISIONS IMPAIRED ? ALL SECTIONS THAT FOLLOW MUST BE COMPLETED. IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS. 1. Diagnosis of the Etiologic Condition(s). (You must be specific. OBS, senility, and other similar terms are not diagnoses.) 2. Severity or stage of the Etiologic Condition(s). (You must be specific in describing the current level of mental function.) 3. Provide historical evidence of the impairment (i.e., examples of the range/scope of problems encountered in daily living). 4. Safety concerns (home and community): 5. What assistance is required? (in place? recommended?) B. IS THE RESPONDENT'S/WARD'S PHYSICAL FUNCTION IMPAIRED? YES NO IF YES, ALL SECTIONS THAT FOLLOW MUST BE COMPLETED. IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS. 1. Diagnosis of the Etiologic Condition(s). (You must be specific. Senility, frailty, failure to thrive, and other similar terms are not diagnoses.) PHYSICIAN'S EVALUATION/CONSERVATORSHIP PC-370 American LegalNet, Inc. www.USCourtForms.com 2. Has the respondent/ward accepted recommended interventions? Yes No. If not, please describe what is refused and the significance of the refusal (for example, refusal of medication for Parkinson's disease or services in the home). 3. Severity or stage of the Etiologic Condition(s). (You must be specific in describing the current level of physical function.) 4. Provide historical evidence of the impairment (i.e., examples of the range/scope of problems encountered in daily living). 5. Safety concerns (home and community): 6. What assistance is required? (in place? recommended?) 7. Is the respondent/ward receiving medication at this time? effects of such medication(s). Yes No If "Yes," please list the medication(s) and the common IF THIS FORM WAS REQUESTED AS PART OF A THREE-YEAR REVIEW OF CONSERVATORSHIP UNDER C.G.S. §45a-660, PLEASE COMPLETE THIS SECTION. In my opinion, the conservatorship should be continued modified terminated. Give reasons for your answer. [To give further details, use additional sheets.] .I hereby certify that I am a licensed physician, and I have personally examined such respondent/ward on the aforementioned date. DATE [Month, day, year] SIGNED [Examining physician] Note to physician: The following are the statutory requirements for the examination of the respondent/ward. INVOLUNTARY PROCEEDINGS. C.G.S. §45a-650. At any hearing for involuntary representation, the court shall receive evidence regarding the condition of the respondent, including a written report or testimony by one or more physicians licensed to practice medicine in the state who have examined the respondent within thirty days preceding the hearing. The report or testimony shall contain specific information regarding the disability and the extent of its incapacitating effect....If the court finds by clear and convincing evidence that the respondent is incapable of managing his or her affairs, the court shall appoint a conservator of his or her estate, unless it appears to the court that such affairs are being managed properly without the appointment of a conservator. If the court finds by clear and convincing evidence that the respondent is incapable of caring for himself or herself, the court shall appoint a conservator of his or her person unless it appears to the court that the respondent is being cared for properly without the appointment of a conservator. REVIEW OF CONSERVATORSHIP. C.G.S. §45a-660(c). The court shall review each conservatorship at least once every three years and shall either continue, modify, or terminate the order for conservatorship. The court shall receive and review written evidence as to the condition of the ward. The conservator, the attorney for the ward, and a physician licensed to practice medicine in this state shall each submit a written report to the court within forty-five days of the court's request for such report.... The physician shall examine the ward within the forty-five day period preceding the date of submission of the physician's report. Any physician's report filed with the court pursuant to this subsection shall be confidential.... PHYSICIAN'S EVALUATION/CONSERVATORSHIP PC-370 (Reverse) REV. 10/04 American LegalNet, Inc. www.USCourtForms.com
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