STATE OF CONNECTICUT APPLICATION FOR INVOLUNTARY RECOMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-804 NEW 10/98 RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF DISTRICT NO. SEX: M F PETITIONER[Name, address, zip code, and telephone number.] Administrator of ,an Inpatient Outpatient Facility SOCIAL SECURITY NO.: Hereinafter referred to as the respondent. PERMANENT ADDRESS OF RESPONDENT JURISDICTION BASED ON RESIDENCE PRESENT ADDRESS OF RESPONDENT [If confined for treatment, give name and address of treatment facility.] DISTRICT WHERE RESPONDENT IS CONFINED FOR TREATMENT 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, NEXT OF KIN [If none, so state], PARENT OR LEGAL GUARDIAN [If the respondent is a minor], ADMINISTRATOR OF THE TREATMENT FACILITY TO WHICH THE RESPONDENT IS TO BE ADMITTED[If different from petitioner], and OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT[Give names, addresses, and zip codes, and relationships to respondent. ] C.G.S. §17a-685. 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 FURTHER REPRESENTS THAT said respondent was committed to , a treatment facility, by order of this Court dated THE PETITIONER RESPECTFULLY ALLEGES that the named respondent resides in the town shown within this probate district or is now at the present address shown and that: The respondent needs further inpatient treatment and is likely to become dangerous to himself or dangerous to others when intoxicated or likely to become gravely disabled and is likely to benefit from such treatment. The respondent is not successfully participating in the outpatient program and is likely to become dangerous to himself or dangerous to others when intoxicated or likely to become gravely disabled and is likely to benefit from such treatment. The petitioner has arranged for treatment in the facility named below, AND A STATEMENT TO THAT EFFECT FROM SAID FACILITY IS ATTACHED HERETO. Name PROPOSED TREATMENT Address and Zip Code FACILITY WHEREFORE,THE PETITIONER REQUESTS that this Court find that the respondent is an alcohol-dependent or drug-dependent person as set forth herein and that said respondent be ordered recommitted to a treatment facility for treatment as provided by C.G.S. §17a-685. The representations contained herein are made under the penalties of false statement. DATE: SIGNED.............................................................................. Petitioner: ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number] APPLICATION FOR INVOLUNTARY RECOMMITMENT/ ALCOHOL AND/OR DRUG DEPENDENCY PC-804 American LegalNet, Inc. www.FormsWorkFlow.com