Physician222s / Commitment of Mentally Ill Child PC-870 REV. 4/19 CONNECTICUT PROBATE COURTS CONFIDENTIAL Physician222s Commitment of Mentally Ill Child PC - 8 7 0 Page 1 of 3 RECEIVED: Instructions: 1) A physician appointed by the Probate Court must complete this form in connection with a petition for commitment of a mentally ill child. The named physician must be licensed to practice medicine in Connecticut and must have examined the child within 10 days of the hearing. 2)For more information, see C.G.S. section 17a-75 et seq.3)Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number The undersigned, a physician appointed by this court to examine the named child, states that he or she has personally examined the respondent and makes the following report: Child (Name and present address) He reinafter referred to as the child Date of Examination Date of Physician222s Appointment Physician (Name, address and telephone number) Connecticut Medical License No. Practicing Psychiatrist Yes No Does the child have a mental disorder? Yes No If yes, you must answer all of the following questions and give reasons for your opinions. 1.What specific type of mental or emotional condition is involved? Give D.S.M. diagnosis. 2.Is the child intellectually disabled? Yes No 3.Does the child222s mental or emotional condition have substantial adverse effects on his or her Yes No ability to function as to jeopardize the child222s health, safety or welfare or that of others? American LegalNet, Inc. www.FormsWorkFlow.com Physician222s / Commitment of Mentally Ill Child PC-870 REV. 4/19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Physician222s /Commitment of Mentally Ill Child PC - 8 7 0 Page 2 of 3 4.Is hospitalization for the treatment of mental illness necessary for the child? Yes No E xplain. 5.Is a less restrictive placement (other than inpatient hospital placement) recommended forthe child? Yes No Pertinent History. (Also indicate who furnished the information and relationship to respondent.) Physical Condition . Psychiatric findings and conclusions . American LegalNet, Inc. www.FormsWorkFlow.com Physician222s / Commitment of Mentally Ill Child PC-870 REV. 4/19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Physician222s /Commitment of Mentally Ill Child PC - 8 7 0 Page 3 of 3 I hereby certify that: I am a physician licensed to practice medicine in the state of Connecticut. I have practiced medicine for at least one year. I personally examined the child on the date of examination listed above. The representations made in this certificate are made under penalty of false statement. Signature of Examining Physician Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com