Petition for Involuntary Commitment Alcohol and/or Drug Dependency PC-803 REV. 4/17 CONNECTICUT PROBATE COURTS CONFIDENTIAL RECEIVED: Instructions: 1) Any person, including a relative or conservator of the person sought to be committed, a physician issuing a certificate under C.G.S. section 17a-685 or the administrator of a treatment facility, may use this form to petition for an order to commit a person to an inpatient facility for the treatment for alcohol dependency or drug dependency. 2) If the respondent is being treated in a facility for the treatment of alcohol or drug dependency at the time of filing, the petition should be filed in the court for the probate district in which the facility is located. If the respondent is not being treated in a facility, the petitioner shall file the petition in the court for the probate district in which the respondent resides, or if the person resides out-of-state or at an unknown address, the petition should be filed in the district where the respondent is located at the time of filing the petition. 3) The petitioner shall arrange for treatment of the respondent in a treatment facility for alcohol dependency or drug dependency. A statement from the treatment facility must be attached to the petition. A certificate from a physician licensed in Connecticut who has examined the person within two days before filing the petition must be filed at or before the hearing on the petition. 4) For more information, see C.G.S. sections 17a-680 et seq. and Rule 46 of the Probate Court Rules of Procedure. 5) Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. District Number Probate Court Name In the Matter of Hereinafter referred to as the respondent. Respondent's Permanent Address Date of Birth M F Present Address of Respondent (If at a treatment facility, name and address of facility.) Petitioner (Name, address and telephone number.) Relationship of Petitioner to Respondent Jurisdiction based on Residence Location of facility in which respondent is being treated District where respondent is located at the time the petition is filed (If the respondent is from out of state or residency is unknown.) Licensed physician who has examined the respondent within two days of filing petition (Name and address.) Petition for Involuntary Commitment/Alcohol and/or Drug Dependency American LegalNet, Inc. www.FormsWorkFlow.com PC-803 Page 1 of 3 Petition for Involuntary Commitment Alcohol and/or Drug Dependency PC-803 REV. 4/17 CONNECTICUT PROBATE COURTS CONFIDENTIAL Name and Address of Persons to Whom Notice Should be Given: (Identify relationships.) Spouse (if not the petitioner), next of kin (including parents if a minor. If none, so state.), administrator of treatment facility in which respondent is located, if any, administrator of facility to which respondent is to be admitted, and persons having an interest in the respondent (e.g. conservator, guardian, etc.) THE PETITIONER REPRESENTS THAT the respondent: Is Is not able to request or obtain an attorney. Is Is not able to pay for the services of an attorney. (Submit Request Order/Waiver of Fees/Respondent, PC184A.) The respondent's financial status is unknown to the petitioner. THE PETITIONER ALLEGES that the respondent is to self or dangerous to others when intoxicated or alcohol-dependent or drug-dependent and is dangerous gravely disabled as defined in C.G.S. section 17a-680. The petitioner is a person other than the certifying physician. The petitioner has filed or will file a certificate from a licensed physician who has examined the respondent within two days before the filing of the petition. A statement of facts and information, including the condition and/or behavior of the respondent and relevant history in support of this allegation, is as follows: The petitioner is the certifying physician who has examined the respondent within two days of the filing of the petition. The petitioner arranged for treatment of the respondent in the facility named below, and a statement to that effect from the facility is attached to the petition. Name of Proposed Treatment Facility Address of Facility Petition for Involuntary Commitment/Alcohol and/or Drug Dependency American LegalNet, Inc. www.FormsWorkFlow.com PC-803 Page 2 of 3 Petition for Involuntary Commitment Alcohol and/or Drug Dependency PC-803 REV. 4/17 CONNECTICUT PROBATE COURTS CONFIDENTIAL WHEREFORE, THE PETITIONER REQUESTS that the court find that the respondent is an alcohol-dependent or drugdependent person in need of treatment and order the respondent to be committed to a facility for treatment as provided in C.G.S. section 17a-685. The representations contained in this petition are made under penalty of false statement. Signature of Petitioner Title Type or Print Name Date Attorney for Petitioner (List name, address, telephone number and juris number.) Attorney shall file an Appearance of Attorney, PC-183. See Probate Court Rules of Procedure, section 5.5 . Petition for Involuntary Commitment/Alcohol and/or Drug Dependency American LegalNet, Inc. www.FormsWorkFlow.com PC-803 Page 3 of 3