CONNECTICUT PROBATE COURTS Conservator222s Report and Petition for Placement in an Institution for Long - Term Care PC - 371A RECEIVED : Instructions: 1) A conservator may use this report to: a) notify the person under conservatorship, the attorney for the person under conservatorship and any other party of an intended placement of the person under 2)The report is required to be filed in both voluntary and involuntary conservatorship proceedings prior tothe intended placement in an institution 4) Type or print the form in ink. Probate Court Name District Number In the Matter of Herein after referred to as the person under conservatorship Present Address of the Person under Conservatorship Conservator of the Person (ame address) Proposed Institution for Long-Term Care (ame and address.) List the reasons for the placement The person under conservatorship agrees does not agree to the placement. Conservator222s Report and Petition for Placement in an Institution for Long-Term Care PC-371A Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Conservator222s Report and Petition for Placement in an Institution for Long - Term Care PC - 371A REV. 4/16 List community resources, if any, that have been considered to avoid placement (including but not limited to area agencies on aging, the Department of Social Services and the Office of Protection and Advocacy for Persons with Disabilities) List the reasons why the physical, mental and psychosocial needs of the person under conservatorship cannot be met in a less restrictive and more integrated setting. This section is to be completed if the placement took place prior to filing the report . The placement was the result of discharge of the person under conservatorship from a hospital Name and address of hospital: Date of discharge from hospital: The placement was not the result of discharge from a hospital. Explain. WHEREFORE, the conservator petitions the court for authority for placement and change of residence of the person under conservatorship to the proposed institution for long term care. The representations contained in this report and petition are made under the penalty of false statement. Signature of Conservator of Person Title Type or Print Name Date Conservator222s Report and Petition for Placement in an Institution for Long-Term Care PC-371A Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Conservator222s Report and Petition for Placement in an Institution for Long - Term Care PC - 371A REV. 4/16 I hereby certify that I sent a copy of this report by first-class mail to the following people as required by C.G.S. section 45a-656b: Signature of Conservator Name and Address Conservator222s Report and Petition for Placement in an Institution for Long-Term Care PC-371A Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com