Petition for Order Authorizing Psychiatric Medication Treatment for Non-Consenting Patient with Psychiatric Disabilities PC-906 NEW 7/15 RECEIVED: CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) Instructions: 1) A facility for the diagnosis, observation or treatment of psychiatric disabilities may use this form to petition the court for an order authorizing psychiatric medication for the treatment of a patient in a hospital for psychiatric disabilities whom the hospital has determined is capable of giving informed consent but has refused psychiatric medication. 2) The petition, with documentation from the head of the hospital for psychiatric disabilities and two qualified physicians, should be filed in the court for the probate district in which the facility is located. 3) For more information, see C.G.S. sections 17a-543 (f) 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 Probate Court Name In the Matter of (List name and present address.) Patient's Residence Address Hereinafter referred to as the patient. Petitioner (List name and address of facility.) Patient's Date of Birth Other Persons to Whom Notice Should Be Given: Spouse, other close relatives and interested parties. (List names and addresses. Identify relationship to patient.) Petition for Order Authorizing Psychiatric Medication Treatment for Non-Consenting Patient with Psychiatric Disabilities PC-906 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Order Authorizing Psychiatric Medication Treatment for Non-Consenting Patient with Psychiatric Disabilities PC-906 NEW 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) THE PETITIONER REPRESENTS THAT: 1) The patient is receiving treatment in the above facility for the diagnosis, observation or treatment of psychiatric disabilities. 2) The head of the facility and two qualified physicians have determined that: a) The patient is capable of giving informed consent to certain medication deemed necessary for treatment of the patient's psychiatric disabilities but has refused to give consent for the medication; b) Without the medication, the diagnosed psychiatric disabilities will continue unabated, placing the patient or others in direct threat of harm; AND c) There is no other less intrusive beneficial treatment available. THE PETITITIONER REQUESTS THAT: The court enter an order authorizing the administration of 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 Petitioner Title Type or Print Name Date Petition for Order Authorizing Psychiatric Medication Treatment for Non-Consenting Patient with Psychiatric Disabilities PC-906 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com