PHYSICIAN'S EVALUATION/ COMMITMENT OF MENTALLY ILL CHILD PC-870 REV. 3/03 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE Instructions 1. Type or print in black ink. 2. Attach additional explanation as needed. 3. Must be signed under penalty of false statement by a physician licensed to practice medicine in the State of Connecticut. 4. Named physician must personally examine child within ten days of the hearing. TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. The undersigned, a physician appointed by this Court to examine the named child, states that he or she has personally examined the child and makes the following report: DATE OF EXAMINATION [Mo., day, year] CHILD [Name, present address, and zip code] DATE OF PHYSICIAN'S APPOINTMENT [Mo., day, year] PHYSICIAN [Name, address, zip code, and telephone no.] PRACTICING PSYCHIATRIST YES NO CONNECTICUT MEDICAL LICENSE NO. IS THE CHILD MENTALLY DISORDERED? YES NO IF YES, ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED. YOU MUST GIVE REASONS FOR YOUR OPINIONS. 1. What specific type of mental or emotional illness is involved? Give diagnosis. (D.S.M.) 2. Is the child mentally retarded? 3. Does the child's mental or emotional condition have substantial adverse effects on his or her ability to function as to jeopardize the child's health, safety, or welfare or that of others? 4. Is psychiatric hospitalization necessary for the child? Is it available? Where? 5. Is a less restrictive placement (other than psychiatric hospitalization ) recommended for the child? Is it available? Where? PERTINENT PSYCHIATRIC HISTORY [Also indicate who furnished information and relationship to child.] PHYSICIAN'S EVALUATION/ COMMITMENT OF MENTALLY ILL CHILD PC-870 Continued American LegalNet, Inc. www.FormsWorkFlow.com PHYSICAL CONDITION PSYCHIATRIC FINDINGS AND CONCLUSIONS I hereby certify that: I am a physician licensed to practice medicine in the state of Connecticut. I have practiced medicine for at least one year. I have personally examined such child on [Insert date] I further certify, that as a result of my examination of the child, that in my opinion, based on the reasons stated above, the child does not have a mental disorder that requires psychiatric hospitalization. has The representations contained herein are made under the penalties of false statement. DATE [Mo., day, year] SIGNED[Examining physician ] Print Name: Note to physician: The following is the statutory requirement for the examination of the child: C.G.S. § 17a-77(b). The court hearing the matter shall require a sworn certificate from at least two impartial physicians selected by the court, one of whom shall be a physician specializing in psychiatry. Both physicians shall be licensed to practice medicine in this state and shall have practiced medicine for at least one year. All appointments shall be made in accordance with procedures adopted by the Judicial Department. If such appointments have not already been made for a case transferred from the Probate Court under C.G.S §§ 17a-76 (b) and (c), then such physicians shall be appointed as soon as reasonably possible by the superior court to which such matter has been transferred. Each physician shall make a report on a separate form adopted for such purpose by the Probate Court Administrator or the Superior Court. The certificates shall include a statement from each physician that he has personally examined such child within ten days of the hearing. The charges for such physicians shall be established by the judicial department and shall be paid in accordance with section 17a-82. PHYSICIAN'S EVALUATION/COMMITMENT OF MENTALLY ILL CHILD PC - 870 (Reverse) REV. 3/03 American LegalNet, Inc. www.FormsWorkFlow.com