Petition/Appointment of Special Limited Conservator with Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-3012 NEW 1/17 RECEIVED: CONNECTICUT PROBATE COURTS CONFI DENTIAL Instructions: 1) A facility for the diagnosis, observation or treatment of psychiatric disabilities may use this form to petition the court for the appointment of a special limited conservator with the authority to consent to the administration of psychiatric medication for the treatment of a patient in the custody of the Commissioner of Mental Health and Addiction Services pursuant to C.G.S. section 54-56d. The form may also be used to request that the court extend the authority of a court-appointed special limited conservator to consent to the medication for an additional period not to exceed 120 days. 2) The petition shall be filed in the district in which the facility is located. The petition shall include documentation from the head of the facility and two qualified physicians in support of the petition. 3) For more information, see C.G.S. sections 17a-543a and 54-56d. 4) Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet, if more space is needed. District Number Probate Court Name In the Matter of (List name and present address.) Patient's Date of Birth Patient's Residence Address Hereinafter referred to as the patient. Petitioner (List name, address and telephone number of facility.) Proposed Special Limited Conservator (List name, address and telephone number.) Persons whom the patient requests that notice be given (List name, address and relationship to patient, if any.) Petition/ Appointment of Special Limited Conservator with Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-3012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition/Appointment of Special Limited Conservator with Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-3012 NEW 1/17 CONNECTICUT PROBATE COURTS CONFI DENTIAL Other persons who have an interest in the patient's welfare to whom notice should be given (List name, address and relationship, if any.) THE PETITIONER REPRESENTS THAT: 1) The patient is a defendant in the custody of the Commissioner of the Department of Mental Health and Addiction Services pursuant to C.G.S. section 54-56d. 2) The head of the facility and two qualified physicians have determined that the patient is incapable of giving informed consent to certain medication for the treatment of the patient's psychiatric disabilities that they deem necessary for the patient's treatment. THE PETITIONER FURTHER REPRESENTS THAT the release of the patient's medical records is necessary to make decisions concerning the patient's treatment, and the patient is unwilling or unable to release the records. THE PETITIONER REQUESTS THAT: The court appoint a special limited conservator who has specific authority to consent to medication for the treatment of the patient's psychiatric disabilities. The court grant the special limited conservator the authority to consent to the release of the patient's medical records to the treating facility. The court extend the authority of the special limited conservator appointed by the court on _______________ to consent to the administration of medication of the treatment of the patient's psychiatric disabilities for a period not to exceed 120 days in accordance with C.G.S. section 17a-543a, without a hearing. The representations made in this petition are made under the penalty of false statement. Signature of Petitioner Title Type or Print Name Date Petition/ Appointment of Special Limited Conservator with Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-3012 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com