EXAMINATION PROCEEDINGS/ MENTALLY ILL CHILD/ EXAMINATION BY COURT PC-881 REV. 5/02 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] COURT OF PROBATE, DISTRICT OF DISTRICT NO. TO: Any state marshal,any police officer, constable, state police officer, any special constable, or any special police officer. CHILD'S DATE OF BIRTH IN THE MATTER OF HEREINAFTER REFERRED TO AS THE CHILD. PETITIONER [Name, address, and zip code] HEARING DATE HEARING TIME PRESENT ADDRESS OF CHILD [If institutionalized, give name and address of institution] HEARING PLACE [Street and town] GENERAL HOSPITAL [Name and Location ] PROPOSED COMMITMENT HOSPITAL [Name, address, and zip code] WARRANT GREETING: Whereas application has been made to this Court alleging that the child named above suffers from a mental disorder and is in need of treatment and; Whereas said child refuses to be examined by physicians lawfully appointed by this Court acting upon such application; Now therefore, you are hereby commanded by the authority of the State of Connecticut forthwith to apprehend said child and take said child to the general hospital named above, there to be personally examined as soon as reasonably possible by two physicians, one of them a psychiatrist and both of them licensed in this state as practitioners of medicine for at least one year. Each of said physicians shall make a separate report on such examination on a probate form (Physician's Evaluation/Commitment of Mentally Ill Child, PC-870) and answer all questions which may be set forth on such forms as fully as reasonably possible, including thereon the reasons for his or her opinion and shall submit such completed form to the Court named above before the date of hearing shown. If, after such examination, either of said physicians determine that the child is in need of immediate hospitalization for evaluation and treatment of a mental disorder, the physician making such determination may cause such respondent to be confined to a hospital for mental illness under a Physician's Emergency Certificate (C.G.S. §17a-78) in accordance with law. In the event such physicians determine after examination that the child is not in need of immediate care and treatment in a hospital for mental illness, said child shall be released forthwith. Dated at: ,Connecticut, on [Month, Day, Year] ................................................................... Judge RETURN By virtue of the foregoing warrant, I apprehended the above-named child and took and delivered said child for examination and action to the general hospital named below, pursuant to said warrant, and there entrusted said child's custody to the duly authorized representative of said hospital named below and read said warrant to said representative in the presence of said child and left a true copy thereof with said representative. RECEIVED BY [Authorized hospital representative's signature] DELIVERED TO [Hospital name] SIGNED AT [Town] TIME DATE [Mo., day, year] SIGNATURE AND DEPARTMENT [Officer] EXAMINATION PROCEEDINGS/MENTALLY ILL CHILD/EXAMINATION BY COURT PC-881 American LegalNet, Inc. www.FormsWorkFlow.com