Petition for Commitment of Mentally Ill Child CONNECTICUT PROBATE COURTS PC - 800 REV. 4 /1 7 CONFIDENTIAL Petition for Commitment of Mentally Ill Child PC - 800 Page 1 of 2 RECEIVED : Instructions: 1) Any person, including a relative or guardian of the child sought to be committed, a physician issuing a certificate under C.G.S. section 17a-78 or the administrator of a hospital for mental illness, may use this form to petition for an order to commit a child to a hospital for mental illness. 2)If the child is being treated in a hospital for mental illness, the petition should be filed in the court forthe probate district in which the hospital is located. If the child is not being treated in a hospital, the petitioner shall file the petition in the court for the probate district in which the child resides, or if the child resides out-of-state or at an unknown address, the petitioner should file the petition in the district where the child is located at the time the petition is filed. 3)For more information, see C.G.S. section 17a-75 et seq. 4) Type or print the form in ink. Use an additional sheet, or PC - 180, if more space is needed. Probate Court Name District Number In the Matter of Hereinafter referred to as the minor child, a proceedin g for commitment. Date of Birth of Child M F Residence Address of Child Present Address of Child (If hospitalized, name and address of hospital.) Petitioner (Name and address) Jurisdiction Based on: Residence District Where Child is Hospitalized District Where Child is at the Time the Petition is Filed (Only if child is from out of state or residency is unknown.) Proposed Hospital ( N ame and address. C.G.S. section 17a-77.) Attorney Appointed for the Child by the Superior Court, if applicable (Name and address. C.G.S. sections 46b-129 and 17a-76.) Persons to Whom Notice Should B e Given: Parents, Guardians, Closest Relatives (if none, so state) and Interested Parties (Names and addresses and relationship to child. If attorney for child or parents, list juris number.) American LegalNet, Inc. www.FormsWorkFlow.com Petition for Commitment of Mentally Ill Child CONNECTICUT PROBATE COURTS PC - 800 REV. 4 /1 7 CONFIDENTIAL Petition for Commitment of Mentally Ill Child PC - 800 Page 2 of 2 The petitioner represents that: The child is now living at the present address written above. The child is is not a patient in a hospital. C.G.S. section 17a-76. The child suffers from a mental disorder and is in need of treatment. WHEREFORE, the petitioner requests that the court make an order for the above child222s confinement to a hospital for mental illness of children. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com