Free PC-850 - Connecticut

PHYSICIAN'S CERTIFICATE/ INVOLUNTARY COMMITMENT/ ANNUAL REVIEW/ PERSON WITH PSYCHIATRIC DISABILITIES PC-850 REV. 9/99
Replaces Form MHCC-4

STATE OF CONNECTICUT COURT OF PROBATE Instructions

RECORDED (CONFIDENTIAL VOLUME):

1. Type or print in black ink. 2. Attach additional explanation as needed. 3. Must be signed under penalty of false statement by a physician licensed to practice medicine in the State of Connecticut. 4. Named physician must personally examine respondent. DISTRICT NO.

TO: COURT OF PROBATE, DISTRICT OF

The undersigned, a physician appointed by this Court to examine the named respondent, states that he or she has personally examined the respondent and makes the following report: RESPONDENT [Name] DATE OF EXAMINATION [Month, day, year]

PHYSICIAN [Name, address, zip code, and telephone no.]

DATE OF PHYSICIAN'S APPOINTMENT [Month, day, year]

PRACTICING PSYCHIATRIST

YES

NO

CONNECTICUT MEDICAL LICENSE NO.

DOES THE RESPONDENT HAVE PSYCHIATRIC DISABILITIES? YES NO IF YES, ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED. YOU MUST GIVE REASONS FOR YOUR OPINIONS. 1. What specific type of psychiatric disability is involved?

2. Is the respondent dangerous to himself or herself ?

3. Is the respondent dangerous to others?

4. Is the respondent gravely disabled?

5. Has the respondent's psychiatric disability resulted in serious disruption of his or her mental and behavioral functioning?

6. Will the respondent's psychiatric disability result in serious disruption of his or her mental and behavioral functioning in the future?

7. Is inpatient hospital treatment necessary for the respondent? Is it available? Where?

8. Is a less restrictive placement (other than inpatient hospital placement) recommended for the respondent? Is it available? Where?

9. Is the respondent capable of understanding the need to accept treatment on a voluntary basis?

Continued PHYSICIAN'S CERTIFICATE/ INVOLUNTARY COMMITMENT/ANNUAL REVIEW/ PERSON WITH PSYCHIATRIC DISABILITIES PC-850 RESET

PERTINENT HISTORY [Also indicate who furnished information and relationship to respondent.]

PHYSICAL CONDITION

MENTAL CONDITION

I hereby certify that: I am a physician licensed to practice medicine in the state of Connecticut. I have practiced medicine for at least one year. I am not connected to the hospital for psychiatric disabilites to which application for commitment of the respondent is being made. I am not related by blood or marriage to either the applicant or the respondent. I further certify, as a result of my examination of the respondent, that, in my opinion, based on the reasons stated above, the respondent has psychiatric disabilities and is: dangerous to himself or herself dangerous to others

gravely disabled I further certify that the facts stated and information contained in this certificate are true and complete to the best of my knowledge andbelief. The representations contained herein are made under the penalties of false statement. DATE [Month, day, year] SIGNED[Examining Physician] Print Name: PHYSICIAN'S CERTIFICATE/INVOLUNTARY COMMITMENT/ANNUAL REVIEW/PERSON WITH PSYCHIATRIC DISABILITIES PC - 850 (Reverse) REV. 9/99 RESET