Free PC-371A - Connecticut

RECORDED(CONFIDENTIAL VOLUME): CONSERVATOR'S REPORT/PLACEMENT OR STATE OF CONNECTICUT REQUEST FOR HEARING ON PLACEMENT/ CHANGE OF RESIDENCE COURT OF PROBATE [Type or print in black ink.] PC-371A REV. 10/08 [Use additional sheets if more space is required.] PLEASE SEE IMPORTANT NOTICE ON REVERSE SIDE.

TO: COURT OF PROBATE, DISTRICT OF

DISTRICT NO.

IN THE MATTER OF [Name, address, zip code, and date of birth] PRESENT ADDRESS OF CONSERVED PERSON

HEREINAFTER REFERRED TO AS THE "CONSERVED PERSON."

PRESENT TREATING PHYSICIAN [Name, address, and zip code. ]

CONSERVATOR OF THE PERSON [Name, address, zip code, and telephone number.]

This conservator's report is being filed for the following reason:[P.A. 07-116, Section 21] Intended placement of the conserved person in an institution for long-term care or change of residence. [List either name and address of proposed institution for long-term care or proposed new address.]

Placement of the conserved person in an institution for long-term care has taken place, and this report is being filed within five days of placement. List the reasons for placement. [Be specific.]

SPECIAL NOTICE TO CONSERVED PERSON: You may, at any time, request a hearing to have the Court review your placement in an institution for long-term care. If you wish to request such a hearing, please complete the form on the reverse side. List the community resources, if any, that have been considered to avoid placement. [For example, resources provided by Area Agencies on Aging, the Department of Social Services, and the Office of Protection and Advocacy for Persons with Disabilities.]

List the reason(s) why the conserved person's physical, mental, and psychosocial needs cannot be met in a less restrictive and more integrated setting.

This section is to be completed for placements that took place prior to the filing of the report. Was the placement a result of the conserved person's discharge from a hospital? YES NO

If "YES," please provide a statement about: 1) the discharge from the hospital, including the hospital's name and address and date of discharge, and 2) the related circumstances requiring the conserved person's placement in an institution for long-term care.

I hereby certify that I have given notice of the placement of the conserved person in an institution for long-term care and a copy of this report to the conserved person, the conserved person's attorney, and any interested parties as determined by the Court. Service was by first class mail.

....................................................................................... Conservator: Dated at: ,Connecticut, on [Month, Day, Year]

CONSERVATOR'S REPORT/PLACEMENT OR REQUEST FOR HEARING ON PLACEMENT/CHANGE OF RESIDENCE PC-371A RESET

IMPORTANT NOTICE

To THE CONSERVED PERSON (the person under conservatorship): You have the right, at any time, to request that the Court hold a hearing on your placement in an institution for long-term care. You can exercise this right by advising the Court, in writing, of your desire for a hearing by returning a copy of the form printed below. As a result of such hearing, the Court may determine that your physical, mental, and psychosocial needs can be met in a less restrictive and more integrated setting within the limitations of the resources available to you, either through your own estate or through public or private assistance. If such a determination is made, the Court shall order that you, as the conserved person, be placed and maintained in such a setting.

Dated at:

,Connecticut, on [Month, Day, Year] Fax number:

Court telephone number: The Court's mailing address is:

REQUEST FOR FORMAL HEARING

IN THE MATTER OF: As the conserved person named on the first page, I hereby request a hearing regarding my placement in an institution for long-term care. I understand that I will receive advance written notice of the time and place of the hearing. ............................. Date Signature ..............................................................................

.......................................................................................... [Please type or print name here.] If the address on the envelope you received was incorrect in any way, please correct it below.

CONSERVATOR'S REPORT/PLACEMENT OR REQUEST FOR HEARING ON PLACEMENT/CHANGE OF RESIDENCE PC-371A (Reverse) REV. 10/07 RESET