Petition/Placement of Person with Intellectual Disability with the Department of Developmental Services CONNECTICUT PROBATE COURTS PC - 701 REV. 10 /1 8 CONFIDENTIAL Petition/Placement of Person with Intellectual Disability with the Department of Developmental Services PC-701 RECEIVED : Instructions: 1) Any adult person may use this form to petition to place an adult with intellectual disability in the custody and control of the Department of Developmental Services for placement in an appropriate setting. 223Intellectual disability224 is defined in C.G.S. section 1-1g, as 223a significant limitation in intellectual functioning existing concurrently with deficits in adaptive behavior that originated during the 2)The person for whom placement is being requested is referred to as the respondent.3)The petition should be filed in the court for the probate district in which the respondent resides.5) 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 atter of Hereinafter referred to as the respondent Respondent222s Date of Birth Petitioner (Name, address and telephone number) Respondent222s Residence Address Legal Representative of the Respondent: Guardian or Conservator (Name, address, telephone number and probate district in which Other Persons to Whom Notice Should Be Given: Spouse, the Respondent222s Children, and if none, the Respondent222s Parents, and, if none, the Respondent222s Brothers and Sisters and other Interested Parties (Names, addresses and relationships to respondent) In addition to the persons listed above, the Commissioner of the Department of Developmental Services must be given notice in all cases. American LegalNet, Inc. www.FormsWorkFlow.com Petition/Placement of Person with Intellectual Disability with the Department of Developmental Services CONNECTICUT PROBATE COURTS PC - 701 REV. 10 /1 8 CONFIDENTIAL Petition/Placement of Person with Intellectual Disability with the Department of Developmental Services PC-701 THE PETITIONER REPRESENTS that: The respondent has an IQ of 69 or less. The respondent is unable to provide for himself or herself at least one of the following (check all that apply): education habilitation care for personal and mental health needs meals clothing safe shelter protection from harm The respondent has no family, legal representative or other person to care for him or her. OR The respondent222s family, legal representative or other person can no longer provide adequate care for him or her. The respondent is unable to obtain adequate, appropriate services that would enable him or her to receive care, treatment and education, or habilitation without placement by a probate court. The respondent is not willing to be placed under the custody and control of the Department of Developmental Services or its agents, or voluntary admission has been sought by the legal representative of the respondent, and such voluntary admission has been opposed by the respondent or the respondent222s next of kin. has not received public assistance or institutional care from the State of Connecticut. is not in an institution for persons with psychiatric disabilities in this state. C.G.S. The respondent h The respondent is WHEREFORE THE PETITIONER REQUESTS that the court place the respondent in the custody and control of the Department of Developmental Services for placement in the least restrictive environment available or that can be created within the existing resources of the department. 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