CONNECTICUT PROBATE COURTS Request for Probable Cause Hearing/ Mentally Ill Child PC - 8008 NEW 4/17 Request for Probable Cause Hearing/Mentally Ill Child PC - 8008 Page 1 of 2 RECEIVED : Instructions: 1) A child who is under the age of 16 and hospitalized for evaluation or treatment of a mental disorder under an emergency or diagnostic certificate as provided under C.G.S. section 17a-78 (a), or the child222s representative, may use this form to request a Probate Court hearing to determine if there is probable cause to conclude that the child is subject to involuntary hospitalization pursuant to C.G.S. section 17a-78. 2)The child, or the child222s representative, should submit the form to the head of the hospital.3)The hospital shall immediately file the request in the court of probate for district in which the hospital islocated.4)For more information, see C.G.S. sections 17a-78 and Rule 44 of the Probate Court Rules of Procedure. 5 )Type or print the form in ink. Probate Court Name District Number In the Matter of (Name and present address.) Hereinafter referred to as the child . Date of Birth of Child Child222s Representative (Name, address and relationship to child.) Name and Address Parents of Child (if not listed above) I hereby request a hearing in the Probate Court under C.G.S. section 17a-78 for the purpose of determining if there is probable cause to conclude that I am subject to involuntary hospitalization under C.G.S. section 17a-78, considering my condition at the time of the admission to the hospital and at the time of the hearing, and the effects of medicating, if any, and the advisability of continue treatment based on the testimony of the hospital staff. I understand that: The hearing must be held within seventy-two (72) hours of receipt of this request by the court, excludingSaturdays, Sundays and 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 counsel. If I cannot pay for counsel, counsel will be provided at the State222sexpense. I request the appointment of the attorney whose name and address is below (optional):.I further understand that if the court finds that there is probable cause for involuntary hospitalization under C.G.S. section 17a-78, the court will order my continued hospitalization for the remaining time provided for in the emergency certificate or if a petition for commitment is submitted to the court under C.G.S. section 17a-76, until completion of the commitment proceedings. Date Time Signature of Child Date Time Signature of Child222s Representative, if any American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Request for Probable Cause Hearing/ Mentally Ill Child PC - 8008 NEW 4/17 Request for Probable Cause Hearing/Mentally Ill Child PC - 8008 Page 2 of 2 In the Matter of Hospital Use Only Received by Title Date Time Probate Court Notified Date Notified Time Notified by Court Use only Date Request Received by Court Time Request Received by Court American LegalNet, Inc. www.FormsWorkFlow.com