Petition/Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-309 NEW 7/15 RECEIVED: CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL): Instructions: 1) A conservator previously appointed in an involuntary proceeding may use this form to petition for authority to consent to psychiatric medication for the treatment of a conserved person who is in a facility for psychiatric disabilities. The facility for the diagnosis, observation or treatment of psychiatric disabilities may also use this form to petition the court to grant a conservator authority to consent to psychiatric medication for the treatment of a conserved person who is a patient in hospital for psychiatric disabilities. 2) If a conservator has previously been appointed in an involuntary proceeding, the petition may be filed in the district having jurisdiction over the conservatorship or where the treating facility is located. If a petition for the appointment of a conservator of the person in an involuntary proceeding is being filed with the petition for authority to consent to medication, the petition should be filed in the district having jurisdiction over the conservatorship petition under C.G.S. section 45a-648 (a). 3) For more information, see C.G.S. sections 17a-543 (e) and Rule 45.3 of the Probate Court Rules of Procedure. 4) Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet, if more space is needed. District Number Patient's Date of Birth Probate Court Name In the Matter of (List name and present address.) Hereinafter referred to as the patient. Patient's Residence Address Probate Court Having Jurisdiction over Conservatorship of Patient Petitioner (List name and address.) Petitioner is the: Patient's Conservator Facility Name and Address of Facility (If the facility is not the petitioner.) Other Persons to Whom Notice Should Be Given: Spouse (if not petitioner), other close relatives (if none, so state), conservator, if any, and other interested parties. (List names and addresses. Include relationship to patient.) American LegalNet, Inc. www.FormsWorkFlow.com Petition/Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-309 Petition/Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-309 NEW 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL): THE PETITIONER REPRESENTS THAT: 1) The patient is in the facility for the diagnosis, observation or treatment of psychiatric disabilities. 2) The head of the hospital and two qualified physicians have determined that the patient is incapable of giving informed consent to certain medication, and the medication is necessary for the treatment of the patient's psychiatric disabilities. (Attach documentation from the head of the facility and the two qualified physicians.) 3) ______________________________________ was appointed conservator of the person of the patient by the Probate Court for the District of ____________________________________ dated ___________________ . (Attach a copy of the Probate Court's decree and current Fiduciary's Probate Certificate, PC-450C) OR ____________________________________ is the proposed conservator of the person of the patient in a petition for the appointment of a conservator that has been filed with the court. WHEREFORE, the petitioner requests that the court authorize the duly-appointed conservator of the person to consent to medication for the treatment of the patient's psychiatric disabilities. The representations made in this petition are made under the penalty of false statement. Signature of the Petitioner Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com Petition/Authority to Consent to Psychiatric Medication Treatment for Patient with Psychiatric Disabilities PC-309