APPOINTMENT OF COUNSEL AND STATE OF CONNECTICUT PHYSICIANS/INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES COURT OF PROBATE PC-883 NEW 5/94 [Type or print in black ink.] RECORDED (CONFIDENTIAL VOLUME): Replaces Form MHCC-9 COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF DATE OF APPLICATION Hereinafter referred to as the respondent. PETITIONER [Name, address, zip code, and telephone number] PERMANENT ADDRESS OF RESPONDENT PRESENT ADDRESS OF RESPONDENT [If hospitalized for psychiatric disabilities, give name and address of hospital.] APPOINTMENT OF COUNSEL PROPOSED ATTORNEY [Name, address, zip code, and telephone number] Upon finding by this Court that said respondent is indigent or otherwise unable to pay for counsel OR unable to request counsel OR not presently represented by counsel because the attorney he or she selected is unable to represent the respondent, the Court appoints the proposed attorney, an attorney admitted to practice in this state, to represent said respondent. DATE OF APPOINTMENT SIGNED ............................................................................................................ Judge BY ORDER OF THE COURT Clerk APPOINTMENT OF PHYSICIANS PHYSICIAN [Name, address, zip code, and telephone number] Ass't Clerk Practicing Psychiatrist YES NO PHYSICIAN [Name, address, zip code, and telephone number] Practicing Psychiatrist YES NO This Court further appoints the above-named physicians to personally examine the respondent and make his or her report on a separate form, answering all questions as fully and completely as reasonably possible. The report shall include the reasons for each doctor's opinions. Both doctors must be physicians licensed to practice in this state, and at least one of the doctors must be a practicing psychiatrist. The doctors cannot be connected to the hospital for psychiatric disabilities to which application is being made, nor can they be related by blood or marriage to the petitioner or the respondent. Such examination shall take place within ten days of the date of the hearing on the application. The report shall be presented to this Court on or before the time fixed for said hearing. DATE OF APPOINTMENT SIGNED ............................................................................................................ BY ORDER OF THE COURT APPOINTMENT OF COUNSEL AND PHYSICIANS/INVOLUNTARY COMMITMENT OF PERSON WITH PSYCHIATRIC DISABILITIES PC-883 Judge Clerk Ass't Clerk American LegalNet, Inc. www.FormsWorkFlow.com