RECORDED (CONFIDENTIAL VOLUME): PROBABLE CAUSE HEARING REQUEST C.G.S. §17a-502(d) PC-802 REV. 7/13 TO: Superintendent: RESPONDENT [Name and address] STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] Hospital: RESPONDENT'S REPRESENTATIVE TITLE OR RELATIONSHIP I, the respondent named above, hereby request a hearing under C.G.S. § 17a-502(d) in the Probate Court for the purpose of determining if there is probable cause to conclude that I am subject to involuntary confinement under C.G.S. § 17a-502, considering my condition at the time of admission and at the time of the hearing, the effects of medication, if any, and the advisability of continued treatment based on the testimony of the hospital staff. I understand that the hearing must be held within seventy-two (72) hours of the receipt of this request by the court, excluding Saturdays, Sundays and holidays. I further understand that I have the right to be present at the hearing, to cross-examine any witnesses testifying, and to be represented by counsel. If I cannot pay for counsel, counsel will be provided at the state's expense, and I may request a specific attorney to represent me. I further understand that if the court finds probable cause for my detention under C.G.S. § 17a-502, the court shall order my continued detention for the remaining time provided by the physician's emergency certificate or, if probate proceedings for commitment are commenced, until the completion of probate proceedings. DATE DATE TIME TIME SIGNED [Respondent] SIGNED [Respondent's representative. Give title or relationship of representative to respondent.] Hospital RECEIVED BY [Name] Use Only PROBATE COURT NOTIFIED [District name and number] TITLE DATE RECEIVED TIME RECEIVED NOTIFIED BY [Name] DATE NOTIFIED TIME NOTIFIED Court Use Only DATE REQUEST RECEIVED BY COURT TIME REQUEST RECEIVED BY COURT PROBABLE CAUSE HEARING REQUEST C.G.S. §17a-502(d) American LegalNet, Inc. www.FormsWorkFlow.com PC-802
Success: Your message was sent.