PHYSICIAN'S CERTIFICATE INVOLUNTARY COMMITMENT/ ALCOHOL AND/OR DRUG DEPENDENCY PC-852 REV. 4/17 RECEIVED: CONNECTICUT PROBATE COURTS CONFIDENTIAL Instructions: A Connecticut licensed physician must complete this form in connection with a petition for involuntary commitment for alcohol and/or drug dependency. The physician must have personally examined the patient within 2 days prior to the date the petition is filed in court. 2) The contents of this form will be used by the Probate Court in determining a) whether the patient is an alcohol-dependent and/or a drug-dependent person who is dangerous to himself or herself, dangerous to others when intoxicated or who is gravely disabled and b) the type and length of treatment that would be beneficial to the patient. 3) For more information, see C.G.S. sections 17a-680 and 17a-685. 4) Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. District Number 1) Probate Court Name Patient (Name and present address.) Date Date of Examination Physician (Name, address and telephone number.) Connecticut Medical License No. Employer 1. Medical history. 2. Current findings, including clinical observations or information. 3. Treatment recommendations, including a specific recommendation regarding the type and length of treatment that would be beneficial to the patient. 4. Recommendation of available inpatient facilities, if known. Physician's Certificate/Involuntary Commitment/Alcohol and/or Drug Dependency PC-852 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com PHYSICIAN'S CERTIFICATE INVOLUNTARY COMMITMENT/ ALCOHOL AND/OR DRUG DEPENDENCY PC-852 REV. 4/17 Patient Name: CONNECTICUT PROBATE COURTS CONFIDENTIAL I hereby certify that the above-named individual was examined by me on the date of the evaluation shown above. As a result of my examination, and based on the reasons stated above, it is my opinion that the patient is: alcohol-dependent AND is dangerous to self or others when intoxicated OR gravely disabled as defined in C.G. S. section 17a-680. drug-dependent The individual needs and is likely to benefit from treatment of the type and length indicated above. I am not employed by a private facility to which the individual is to be committed. The representations made in this certificate are made under penalty of false statement. Signature of Examining Physician Type or Print Name Date Sec. 17a-685 (Formerly Sec. 19a-126e). Petition for involuntary commitment. Notice of hearing. Order of Commitment. Recommitment. Discharge. Petition for termination of commitment or recommitment and discharge. (a) Any person, including the spouse, a relative, or a conservator of a person sought to be committed, a physician issuing a certificate under subsection (b) of this section, or the administrator of a treatment facility may make application to the probate court to commit a person to an inpatient treatment facility for treatment for alcohol dependency or drug dependency. The application shall be brought to the probate court for the district in which the respondent resides, or, if his residence is out of state or unknown, for the district in which he is at the time of the filing of the application. In any case in which the person is being treated in a facility, and an application is filed in accordance with the provisions of this section, jurisdiction shall be vested in the probate court for the district in which the facility where such person is a patient is located. If the respondent is confined to a facility, notwithstanding the provisions of Section 45a-7, the judge of probate for the district in which the application was filed shall hold the hearing on the application at the facility where such person is confined. (b) The application shall allege that the person is an alcohol-dependent person or a drug-dependent person who is dangerous to himself or herself or dangerous to others when he or she is an intoxicated person or who is gravely disabled. The application shall contain a statement that the applicant has arranged for treatment in a treatment facility. A statement to that effect from such facility shall be attached to the application. At or before the hearing on the application, there shall be filed with the court a certificate of a licensed physician who has examined the person within two days before submission of the application. The physician's certificate shall set forth the physician's findings, including clinical observation or information, or the person's medical history, in support of the allegations of the application, and a finding of whether the person presently needs and is likely to benefit from treatment, and shall include a recommendation as to the type and length of treatment and inpatient facilities available for such treatment. A physician employed by the private treatment facility to which the person is to be committed is not eligible to be the certifying physician. An application filed by a person other than the certifying physician shall set forth the facts and information upon which the applicant bases his or her allegations and the names and addresses of all physicians. Upon filing of an application under this section, the court may issue an order for the disclosure of the medical information required pursuant to this subsection. Physician's Certificate/Involuntary Commitment/Alcohol and/or Drug Dependency PC-852 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com