Free PC-370 - Connecticut

PHYSICIAN'S EVALUATION/ CONSERVATORSHIP PC-370 REV. 10/07

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink].

RECORDED (CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF

DISTRICT NO.

With the knowledge that the contents of this report will be used as evidence in a judicial proceeding that may result in the loss of some or all of the respondent's/conserved person's rights, the undersigned physician states that he or she has personally examined the respondent/conserved person and makes the following report: RESPONDENT/CONSERVED PERSON[ Name ] PHYSICIAN [Name, address, zip code, and telephone no. ]

PRACTICING PSYCHIATRIST

YES

NO

CONNECTICUT MEDICAL LICENSE NO.

DATE OF EXAMINATION [Month, day, year]

IF "YES," ALL YES NO A. Is the respondent's/conserved person's capacity to make decisions impaired? SECTIONS THAT FOLLOW MUST BE COMPLETED. IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS. 1. Diagnosis of the Etiologic Condition(s). (You must be specific. OBS, senility, and other similar terms are not diagnoses.)

2. Severity or stage of the Etiologic Condition(s). (You must be specific in describing the current level of mental function.)

3. Provide historical evidence of the impairment (i.e., examples of the range/scope of problems encountered in daily living).

4. Safety concerns (home and community):

5. What assistance is required? (in place? recommended?)

B. Is the respondent's/conserved person's physical function impaired?

YES

NO

IF "YES," ALL SECTIONS

THAT FOLLOW MUST BE COMPLETED. IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS. 1. Diagnosis of the Etiologic Condition(s). (You must be specific. Senility, frailty, failure to thrive, and other similar terms are not diagnoses.)

Continued PHYSICIAN'S EVALUATION/CONSERVATORSHIP PC-370

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2. Has the respondent/conserved person accepted recommended interventions? Yes No. If not, please described what is refused and the significance of the refusal (for example, refusal of medication for Parkinson's disease or services in the home.)

3. Severity or stage of the Etiologic Condition(s). (You must be specific in describing the current level of physical function.)

4. Provide historical evidence of the impairment (i.e., examples of the range/scope of problems encountered in daily living).

5. Safety concerns (home and community):

6. What assistance is required? (in place? recommended?)

7. Is the respondent/conserved person receiving medication at this time? and the common effects of such medication(s).

Yes

No. If "Yes," please list the medication(s) and

IF THIS FORM WAS REQUESTED AS PART OF A REVIEW OF CONSERVATORSHIP UNDER C.G.S. §45a-660, PLEASE COMPLETE THIS SECTION. In my opinion, the conservatorship should be continued modified Give reasons for your answer. [To give further details, use additional sheets.]

terminated.

.I hereby certify that I am a licensed physician, and I personally examined such respondent/conserved person on the aforementioned date. DATE [Month, day, year] SIGNED [Examining physician]

Print Name: Note to physician: The following are the statutory requirements for the examination of the respondent/conserved person. INVOLUNTARY PROCEEDINGS. C.G.S. §45a-650. At any hearing on an application for involuntary representation,. . . the court shall receive evidence regarding the respondent's condition, the capacity of the respondent to care for himself or herself or to manage his or her affairs, and the ability of the respondent to meet his or her needs without the appointment of a conservator. Unless waived by the court pursuant to this subsection, evidence shall be introduced from one or more physicians licensed to practice medicine in the state who have examined the respondent within forty-five days preceding the hearing. The evidence shall contain specific information regarding the respondent's condition and the effect of the respondent's condition on the respondent's ability to care for himself or herself or to manage his or her affairs. ...If the court finds by clear and convincing evidence that the respondent is incapable of managing the respondent's affairs. . . the court may appoint a conservator of his or her estate. . . . If the court finds by clear and convincing evidence that the respondent is incapable of caring for himself or herself, . . . the court may appoint a conservator of his or her person. . . . REVIEW OF CONSERVATORSHIP. C.G.S. §45a-660(c). The court shall review each conservatorship not later than one year after the conservatorship was ordered and not less than every three years after such initial one-year review. After each such review, the court shall continue, modify, or terminate the order for conservatorship. The court shall receive and review written evidence as to the condition of the conserved person. The conservator and a physician licensed to practice medicine in this state shall each submit a written report to the court within forty-five days of the court's request for such report. . . .The physician shall examine the conserved person within the forty-five day period preceding the date of submission of the physician's report. Any physician's report filed with the court pursuant to this subsection shall be confidential.
PHYSICIAN'S EVALUATION/CONSERVATORSHIP PC-370 (Reverse) REV. 10/07

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