Psychologist222s Evaluation/ Conservatorship of Person with Intellectual Disability PC - 372 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Psychologist222s Evaluation/Conservatorship of Person with Intellectual Disability PC - 372 Page 1 of 4 RECEIVED: Instructions: 1) A psychologist may be requested to complete this form in connection with an involuntary proceeding for the appointment of a conservator of the person or estate for a respondent with intellectual disability as defined by C.G.S. section 1-1 g or review of a conservatorship for an adult with intellectual disability previously established by the Probate Court. 223Intellectual disability224 is defined in C.G.S. section 1-1g as 223a significant limitation in intellectual functioning existing concurrently with deficits in adaptive behavior that originated during the developmental period before eighteen years of age.224 A 223significant limitation in intellectual functioning224 is defined as an intelligence quotient (223IQ224) more than two standard deviations below the mean, as measured by standard tests of general intellectual functioning. This means that the person222s IQ must be 69 or less. 2)The named psychologist must be licensed to practice in Connecticut and must have personallyexamined the patient on the Date of Examination listed below. 3) Type or print in ink. Use an additional sheet, or PC - 180, if more space is needed. Probate Court Name District Number Patient Psychologist (Nam e, address and telephone number ) Date of Examination Place of Examination Treating Psychologist Professional relationship to patient: Consultation/Evaluation If you are a treating psychologist, how long have you treated this patient? 1.Intellectual Disability Is the patient a person with intellectual disability, which is defined in C.G.S. section 1-1g as 223a significant developmental limitation in intellectual functioning and deficits in adaptive behavior that originated during the developmental period before eighteen years of age224? See C.G .S. section 1-1g for a complete definition of intellectual disability. Yes No Is your conclusion supported by a psychological evaluation? Yes No If yes, please attach. If no, please provide the basis for your conclusion in the space below. American LegalNet, Inc. www.FormsWorkFlow.com Psychologist222s Evaluation/ Conservatorship of Person with Intellectual Disability PC - 372 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Psychologist222s Evaluation/Conservatorship of Person with Intellectual Disability PC - 372 Page 2 of 4 2 .Capacity Is the patient222s capacity to make financial decisions impaired? Yes No Is the patient222s capacity to make personal decisions impaired? Yes information or make or communicate decisions about the patient222s personal or financial affairs Yes No Does the patient222s intellectual disability result in the patient being unable to receive or evaluate as indicated above? No If yes, please complete all sections below. Please give specific examples of recent history known to you that contribute to your answers below. If more space is required, use additional sheets. 2 a . Does the p atient222s intellectual disability affec t the respondent222s ability to seek or obtain medical care? Yes No If yes, give specific examples. 2 b . Does the patient222s intellectual disability affect the patient222s ability to secure and maintain a safe living environment? Yes No If yes, give specific examples. 2 c . Does the patient222s intellectual disability affect the patient222s ability to independently manage financial affairs? Yes No If yes, give specific examples. American LegalNet, Inc. www.FormsWorkFlow.com Psychologist222s Evaluation/ Conservatorship of Person with Intellectual Disability PC - 372 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Psychologist222s Evaluation/Conservatorship of Person with Intellectual Disability PC - 372 Page 3 of 4 2d. Does the patient222s intellectual disability raise safety concerns, including the patient222s ability to seek protection from physical abuse or harm or financial exploitation? Yes No If yes, give specific examples. 2 e . Are there treatments or rehabilitative factors that can be expected to significantly improve the patient222s ability to self - care or self - manage the patient222s personal or financial affairs? Yes No If yes, specify the treatments or factors. 2 f. Are there other illnesses or conditions affecting the patient222s ability to ma nage his or her own personal or financial affairs? Yes No If yes, specify the illness or condition. 3.Medications, Treatments and Other Interventions 3 a. List all medications prescribed. Is the patient capable of managing his/her medications? Yes No 3b. Do any of these medications impact mental functioning? Yes No Uncertain American LegalNet, Inc. www.FormsWorkFlow.com Psychologist222s Evaluation/ Conservatorship of Person with Intellectual Disability PC - 372 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Psychologist222s Evaluation/Conservatorship of Person with Intellectual Disability PC - 372 Page 4 of 4 Yes No 3c. Is t he patient capable of understanding the need to accept assistance, treatment or other interventions? Explain. 4.Additional information Include any other relevant information you believe should be presented to the court. 5.Review of conservatorship If this form was requested in conjunction with a review of the conservatorship under C.G.S. section 45a-660, please also complete this section. In my opinion, the conservatorship should be continued modified terminated. Specify your reasons for your opinion. If more space is required, use additional sheets. I hereby certify that: I am a licensed ps ychologist . I personally examined the respondent on the above - referenced date. Signature of Examining Psychologist Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com