Petition for Involuntary Commitment of Person with Psychiatric Disabilities PC-801 REV. 12/16 CONNECTICUT PROBATE COURTS CONFIDENTIAL RECEIVED: Instructions: 1) An authorized representative of a hospital or any other person may use this form to petition for an order to commit a person with psychiatric disabilities to a hospital for psychiatric disabilities. 2) The petition should be filed in the court for the probate district in which the hospital is located, if the person is hospitalized. If the person is not hospitalized, the petition should be filed in the district in which the person resides or, if the person resides out-of-state or residence is not known, the probate district in which the person is located at the time of filing the petition. 3) For more information, see C.G.S. sections 17a-495 et seq. and Rule 44 of the Probate Court Rules of Procedure. 4) Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. District Number Probate Court Name In the Matter of Sex M Respondent's Social Security Number Respondent's Date of Birth Hereinafter referred to as the respondent. Respondent's Permanent Address F Present Address of Respondent (If hospitalized for psychiatric disabilities, give name and address of hospital.) Petitioner (List name, address and telephone number.) Relationship of Petitioner to Respondent Jurisdiction based on Residence District Where Respondent is Hospitalized for Psychiatric Disabilities District Where Respondent is Located at the Time the Petition is Filed (If the respondent is from out-of-state or residency is unknown.) Name and Address of Other Persons to Whom Notice Should be Given: (Identify relationships.) Spouse (if not the petitioner), closest relatives (If none, so state), and interested parties (e.g. conservator, guardian, etc.) Petition for Involuntary Commitment of Person with Psychiatric Disabilities American LegalNet, Inc. www.FormsWorkFlow.com PC-801 Page 1 of 3 Petition for Involuntary Commitment of Person with Psychiatric Disabilities PC-801 REV. 12/16 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of: THE PETITIONER REPRESENTS THAT the respondent: Is Is not able to request or obtain an attorney. Is Is not able to pay for the services of an attorney. (Submit Request Order/Waiver of Fees/Respondent PC184A.) THE PETITIONER RESPECTFULLY ALLEGES in accordance with C.G.S. section 17a-497 that the respondent has psychiatric disabilities and is dangerous to himself or others or gravely disabled in the following respects: (Describe condition and/or behavior of the respondent to support this allegation, including diagnosis, if any, and relevant history.) IF THE RESPONDENT IS HOSPITALIZED FOR PSYCHIATRIC DISABILTIES, CHECK THE APPROPRIATE BOX(ES): THE PETITIONER REPRESENTS THAT the respondent is hospitalized as a result of: Emergency Commitment. C.G.S. section 17a-502 (a). A patient hospitalized for emergency diagnosis, observation or treatment upon certification of a qualified physician. Voluntary Admission. C.G.S. section 17a-506 (a). A patient sixteen years of age or older who applies in writing to, and is admitted to, a hospital for psychiatric disabilities a person with psychiatric disabilities. Explain: An order of the Superior Court that the respondent be placed with the Commissioner of Mental Health and Addiction Services for the purpose of civil commitment. C.G.S. section 54-56d. The Superior Court has found that the respondent is not competent to stand trial. THE PETITIONER FURTHER represents that a member of the hospital staff offered the respondent voluntary status within twenty-four hours of the filing of this petition and the respondent: Did not accept voluntary status. Is not capable of making this election. Petition for Involuntary Commitment of Person with Psychiatric Disabilities American LegalNet, Inc. www.FormsWorkFlow.com PC-801 Page 2 of 3 Petition for Involuntary Commitment of Person with Psychiatric Disabilities PC-801 REV. 12/16 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of: WHEREFORE, THE PETITIONER REQUESTS that this court order that the respondent be committed to a hospital for psychiatric disabilities. The representations contained in this petition are made under the penalty of false statement. Signature of Petitioner Title Type or Print Name Date Name and address: PROPOSED HOSPITAL FOR PSYCHIATRIC DISABILITIES Attorney for Petitioner (List name, address, telephone number and juris number.) Attorney shall file an Appearance of Attorney, PC- 183. See Probate Court Rules, section 5.5. . Petition for Involuntary Commitment of Person with Psychiatric Disabilities American LegalNet, Inc. www.FormsWorkFlow.com PC-801 Page 3 of 3