CONNECTICUT PROBATE COURTS Probable Cause Hearing Request (Adult) PC - 802 R EV . 4 / 19 CONFIDENTIAL Probable Cause Hearing Request (Adult) PC - 802 RECEIVED: I hereby request a hearing under C.G.S. section 17a-502(d) in the Probate Court to determine if there is probable cause to conclude I am subject to involuntary confinement, considering my condition at the time of my admission to the hospital and at the time of the hearing, the effects of medication, if any, and the advisability of continued treatment based on the testimony of the hospital staff. I understand that: The hearing must be held within 72 hours of receipt of this request by the court, excluding Saturdays, Sundaysand holidays.I have the right to be present at the hearing and to cross examine all witnesses who testify. I have a right to be represented by an attorney. If I cannot pay for an attorney, an attorney will be provided at the state222s expense and I may request a specific attorney to represent me. I further understand that if the court finds probable cause for my confinement, the court will order my continued confinement for the remaining time provided by the physician222s emergency certificate or, if a petition for involuntary commitment is submitted to the court under C.G.S. section 17a-498, until completion of the commitment proceedings. Signature of Respondent or Representative Type or Print Name Date Time Hospital Use Only Received by Title Date Received Time Received Probate Court Notified Notified by Date Notified Time Notified Court Use only Date Request Received by Court Time Request Received by Court Instructions: 1) A ny person who is involuntarily confined to a hospital for psychiatric disabilities , or his or her representative, may use this form to request a hearing to determine whether there is probable cause to continue the confinement for further treatment. 2)The request for hearing must be filed immediately in the court for the probate district in which thehospital is located. 3)For more information, see C.G.S. section 17a-502(d).4)Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number TO: Superintendent: Hospital: Respondent (Name and address) Respondent222s Representative Title or Relationship American LegalNet, Inc. www.FormsWorkFlow.com