Petition/Order Authorizing Shock Therapy for Patient with Psychiatric Disabilities PC-805 REV. 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) RECEIVED: 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 shock therapy for the treatment of a patient in a hospital for psychiatric disabilities whom the hospital has determined is incapable of giving informed consent. 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 patient is hospitalized. 3) For more information, see C.G.S. section 17a-543(c) and Rule 45.5 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 Residence Address Probate Court Name In the Matter of (List name and present hospital address.) Hereinafter referred to as the patient. Petitioner (List name, address and telephone number of facility.) Patient's Date of Birth Facility to Administer Shock Therapy Shock Therapy Requested Other Persons to Whom Notice Should Be Given: Spouse, other close relatives and interested parties. (List names and addresses. Identify relationship to the patient.) 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 shock therapy requested is necessary for the treatment of the patient's psychiatric disabilities. b) The patient is incapable of giving informed consent to the shock therapy; and c) There is no other less intrusive beneficial treatment. Petition/Order Authorizing Shock Therapy for Patient with Psychiatric Disabilities American LegalNet, Inc. www.FormsWorkFlow.com PC-805 Page 1 of 2 Petition/Order Authorizing Shock Therapy for Patient with Psychiatric Disabilities PC-805 REV. 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) 3) The patient is is not able to request an attorney. The patient is is not able to pay for the services of the attorney. (If no, submit Request Order/Waiver of Fees/ Respondent, PC-184A.) The respondent's financial status is not known to the petitioner. THE PETITIONER REQUESTS THAT: The court enter an order authorizing the administration of the shock therapy requested above 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 American LegalNet, Inc. www.FormsWorkFlow.com Petition/Order Authorizing Shock Therapy for Patient with Psychiatric Disabilities PC-805 Page 2 of 2