EXAMINATION PROCEEDINGS/ PERSON WITH PSYCHIATRIC DISABILITIES/ EXAMINATION BY COURT C.G.S §17a-503(b) PC-882 REV. 11/04 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] Replaces form MHCC-12 DISTRICT NO. COURT OF PROBATE, DISTRICT OF TO: Any state marshal, any police officer, constable, state police officer, any special constable, or any special police officer. WARRANT RESPONDENT [Name] OF [Town in Connecticut] GREETING: Upon application made to this Court alleging that the respondent named above has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled, and in need of immediate care and treatment in a hospital for psychiatric disabilities, you are hereby commanded by the authority of the State of Connecticut forthwith to apprehend said respondent and bring said respondent before this Court for examination by the Court to determine whether there is probable cause to believe said respondent has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled, and in need of immediate care and treatment in a hospital for persons with psychiatric disabilities, and for further order of the Court, accordingly. SIGNATURE SIGNED AT [Town] DATE [Mo., day, year] .......................................................................... Judge RETURN By virtue of the foregoing warrant, I apprehended the above-named respondent and read the same in the hearing of said respondent and have said respondent here in court for examination and further order of the Court. DATE [Mo., day, year] SIGNED AT [Town] SIGNATURE AND DEPARTMENT [Officer] ORDER RESPONDENT [Name] EXAMINING COURT [Street and Town] Acting upon an application on file in the records of the court and upon examination by this Court of the respondent named above, this Court determines that: there is no probable cause to believe that the respondent has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled, and in need of immediate care and treatment in a hospital for persons with psychiatric disabilities, and, accordingly, orders the officer executing this warrant to forthwith release said respondent from custody imposed by this warrant. there is probable cause to believe that the respondent has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled and in need of immediate care and treatment in a hospital for persons with psychiatric disabilities. Accordingly, this Court orders the officer executing this warrant to take said respondent to the general hospital named below for a medical examination. The person shall be examined within 24 hours and shall not be held for more than 72 hours, unless he or she is committed under section 17a-502. Such examination shall be conducted to determine whether the respondent has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled and in need of immediate care and treatment in a hospital for persons with psychiatric disabilities, through confinement under an emergency certificate in accordance with the law. GENERAL HOSPITAL [Name and Location ] SIGNED AT [Town] DATE [Mo., day, year] SIGNATURE ................................................................................... Judge RETURN By virtue of the foregoing ORDER, I took and delivered said respondent to the general hospital named below for examination and action pursuant to the ORDER and entrusted said respondent to the duly-authorized representative of said hospital named below and read said ORDER to said representative in the presence of said respondent and left a true copy thereof with said representative. DELIVERED TO [Hospital] DULY-AUTHORIZED HOSPITAL REPRESENTATIVE [Name] SIGNED AT [Town] TIME DATE [Mo., day, year] SIGNATURE AND DEPARTMENT [Officer] EXAMINATION PROCEEDINGS/PERSON WITH PSYCHIATRIC DISABILITIES/EXAMINATION BY COURT American LegalNet, Inc. PC-882 www.FormsWorkFlow.com