APPLICATION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 REV. 10/06 Page 1 of 2 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] Replaces Forms MHCC-8 and 8A TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF RESPONDENT'S SOCIAL SECURITY NUMBER SEX: M F RESPONDENT'S DATE OF BIRTH Hereinafter referred to as the respondent PETITIONER [Name, address, zip code, and telephone number] PERMANENT ADDRESS OF RESPONDENT JURISDICTION BASED ON RESIDENCE RELATIONSHIP OF PETITIONER TO RESPONDENT PRESENT ADDRESS OF RESPONDENT [If hospitalized for psychiatric disabilities, give name and address of hospital.] DISTRICT WHERE RESPONDENT IS HOSPITALIZED FOR PSYCHIATRIC DISABILITIES DISTRICT WHERE RESPONDENT IS AT THE TIME THE APPLICATION IS FILED [If the respondent is from out of state or residency is unknown.] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PETITIONER, SPOUSE [If not the petitioner], CLOSEST RELATIVES [If none, so state], and INTERESTED PARTIES as defined in Probate Practice Book, Rule 3.1.02 [e.g. conservators, guardians, etc. Give names, addresses, and zip codes, and relationships to respondent.] C.G.S. §17a-498. THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not able to request or obtain an attorney. C.G.S. §17a-498(b). Is Is not able to pay for the services of an attorney. [Submit Request Order/Waiver of Fees-Respondent, PC-184A.] The respondent's financial status is unknown to the petitioner. THE PETITIONER RESPECTFULLY ALLEGES in accordance with C.G.S.§17a-497 that the named respondent resides in the town shown within this probate district or is now at the present address shown and that said respondent has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled in the following respects:[Describe condition and/or behavior of respondent to support this allegation, including diagnosis, if any.] APPLICATION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CONNECTICUT APPLICATION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 REV. 8/01 Page 2 of 2 RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] Replaces Forms MHCC-8 and 8A IF THE RESPONDENT IS HOSPITALIZED FOR PSYCHIATRIC DISABILITIES, CHECK THE APPROPRIATE BOX(ES): Involuntary Admission [C.G.S.§17a-498(c)]. Any patient hospitalized pursuant to an order of a judge of the probate court after an appropriate hearing. Emergency Commitment [C.G.S. §17a-502(a)]. A patient hospitalized for emergency diagnosis, observation, or treatment upon certification of a qualified physician. Voluntary Admission [C.G.S. §17a-506(a)]. Any patient sixteen years of age or older who applies in writing to, and is admitted to, a hospital for psychiatric disabilities as a person with psychiatric disabilities. Explain: Informal Admission [C.G.S. §17a-507]. A patient admitted to any general hospital having psychiatric facilities for observation and treatment without formal or written application. The undersigned, if the hospital superintendent or his/her authorized representative, further states that voluntary status was offered to the respondent within twenty-four hours of the time of this application and was refused. [C.G.S. §17a-498(e).] WHEREFORE, PETITIONER REQUESTS that this Court make an order for the above-named respondent's confinement to a hospital for psychiatric disabilities. The representations contained herein are made under the penalties of false statement. Date: PROPOSED HOSPITAL FOR PSYCHIATRIC DISABILITIES ............................................................................ Petitioner: Name Address and Zip Code ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number] APPLICATION FOR INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-801 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com