Free PC-802 - Connecticut

PROBABLE CAUSE HEARING REQUEST C.G.S. §17a-502(d) PC-802 NEW 5/94
Replaces Form MHCC-6

STATE OF CONNECTICUT
RECORDED (CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] Hospital: RESPONDENT'S REPRESENTATIVE

TO: Superintendent: RESPONDENT [Name, address, and zip code]

TITLE OR RELATIONSHIP

I, the respondent named above, hereby request a hearing under C.G.S.§17a-502(d) in the probate court for the purpose of determining if there is probable cause to conclude that I am subject to involuntary confinement under C.G.S.§17a-502, considering my condition at the time of admission and at the time of the hearing; the effects of medication, if any; and the advisability of continued treatment based on the testimony of the hospital staff. I understand that said hearing must be held within seventy-two (72) hours of the receipt of this request by the court, excluding Saturdays, Sundays, and holidays. I further understand that I have the right to be present at said hearing, to cross-examine any witnesses testifying, and to be represented by counsel. If I cannot pay for counsel, counsel will be provided at the state's expense, and I may, if I wish, request a specific attorney to represent me. I further understand that if said Court finds there is probable cause for my detention under C.G.S.§17a-502, said Court shall order my continued detention for the remaining time provided by the physician's emergency certificate or, if probate proceedings for commitment are commenced, until the completion of probate proceedings.
DATE TIME SIGNED [Respondent]

DATE

TIME

SIGNED [Respondent's representative. Give title or relationship of representative to respondent.]

RECEIVED BY [Name]

TITLE

DATE RECEIVED

TIME RECEIVED

Hospital Use PROBATE COURT NOTIFIED [Town and district no.] Only

NOTIFIED BY [Name]

DATE NOTIFIED

TIME NOTIFIED

PROBABLE CAUSE HEARING REQUEST C.G.S. §17a-502(d) PC-802

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