Petition for Involuntary Recommitment Alcohol and/or Drug Dependency PC-804 REV. 4/17 CONNECTICUT PROBATE COURTS CONFIDENTIAL RECEIVED: Instructions: 1) The administrator of an inpatient treatment facility or outpatient treatment facility may use this form to petition for an order to recommit a person to an inpatient facility for the treatment of alcohol dependency or drug dependency. 2) The petition must be filed in the probate court that ordered the commitment prior to the expiration of the commitment period. 3) For more information, see C.G.S. sections 17a-680 et seq. and Rule 46 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 M Hereinafter referred to as the respondent. Present Address of Respondent (Name and address of facility.) F Respondent's Permanent Address Petitioner: Administrator of an inpatient facility outpatient facility (Name, address and telephone number.) Name and Address of Persons to Whom Notice Should be Given: (Identify relationships.) Spouse (if not the petitioner), next of kin, including parents if a minor. (If none, so state.), the petitioner for the original commitment proceeding, and persons having an interest in the respondent (e.g. conservator, guardian, etc.) 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.) PC-804 Page 1 of 2 The respondent's financial status is unknown to the petitioner. Petition for Involuntary Recommitment/Alcohol and/or Drug Dependency American LegalNet, Inc. www.FormsWorkFlow.com Petition for Involuntary Recommitment Alcohol and/or Drug Dependency PC-804 REV. 4/17 CONNECTICUT PROBATE COURTS CONFIDENTIAL THE PETITIONER FURTHER REPRESENTS that The respondent is an alcohol-dependent and/or a drug-dependent person who is dangerous to self or dangerous to others when intoxicated or gravely disabled as defined in C.G.S. section 17a-680. The respondent was committed by decree dated: to: treatment of alcohol dependency or drug dependency. The respondent is in need of further inpatient treatment and is likely to benefit from the treatment. , a facility for the The respondent was discharged from inpatient treatment and referred to an outpatient treatment facility pursuant to the provisions of C.G.S. section 17a-685 (j). The respondent is not successfully participating in the outpatient program. The petitioner has arranged for treatment of the respondent in the inpatient facility named below and a statement to that effect from the facility is attached to the petition. Name of Proposed Treatment Facility Address of Facility WHEREFORE, THE PETITIONER REQUESTS that the court find that the respondent is an alcohol-dependent or drugdependent person in need of treatement and order the respondent to be recommitted to a facility for treatment as provided in C.G.S. section 17a-685. The representations contained in this petition are made under penalty of false statement. Signature of Petitioner Title Type or Print Name Date Attorney for Petitioner (Name, address, telephone number and juris number.) Attorney shall file an Appearance of Attorney, PC- 183. See Probate Court Rules of Procedure, section 5.5 Petition for Involuntary Recommitment/Alcohol and/or Drug Dependency American LegalNet, Inc. www.FormsWorkFlow.com PC-804 Page 2 of 2