PSYCHOLOGIST'S REPORT/ PLACEMENT OF PERSON WITH MENTAL RETARDATION PC-772 REV. 10/07 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink. ] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF RESPONDENT'S DATE OF BIRTH Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [If institutionalized, give PETITIONER [Name, address, zip code, and telephone number] name and address of institution.] PSYCHOLOGIST SELECTED BY THE COURT [Name, address, zip code, and telephone number] CONN. PSYCHOLOGIST'S LIC. NO. DATE OF EXAM [Month, day, year] PSYCHOLOGIST SELECTED BY RESPONDENT, if any [Name, address, zip code, and telephone number] CONN. PSYCHOLOGIST'S LIC. NO. DATE OF EXAM [Month, day, year] ATTORNEY(S) OF RECORD [Name, address, zip code, telephone number, and juris number. ] Is the respondent mentally retarded as defined in C.G.S. §1-1g ? must give reasons for your opinions. Yes No Answer ALL of the following questions. You Please explain the results of any psychological assessment given within the past year. [Identify all standard assessments used.] What were the results of your interview with, or your observation of, the respondent? Please provide an evaluation of the adaptive behavior of the respondent, including a statement of the respondent's needs. ............................................................................................................ Psychologist: NOTE TO PSYCHOLOGIST: This form should be returned to the Court and duplicate copies filed with the Commissioner of Developmental Services and all attorneys of record at least five (5) days prior to the hearing. The following is the statutory requirement for the examination of the respondent [C.G.S.§17a-274(f)]. "Such report shall include a statement as to whether the respondent is mentally retarded and an explanation of how the determination was reached. The explanation shall include the results of a psychological assessment within the past year, an interview or observation of the respondent, and an evaluation of adaptive behavior. Such report shall include a statement of the respondent's needs. Duplicate copies of the report shall be filed with the Commissioner of Developmental Services and all attorneys of record at least five days prior to the hearing. The Court shall order the psychologist to appear for cross-examination at the request of the respondent if the respondent makes such request at least three days before the hearing." PSYCHOLOGIST'S REPORT/ PLACEMENT OF PERSON WITH MENTAL RETARDATION PC-772 American LegalNet, Inc. www.FormsWorkFlow.com