Free PC-701 - Connecticut

APPLICATION/PLACEMENT OF PERSON WITH MENTAL RETARDATION PC-701 REV. 10/07

STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] DISTRICT NO.
RESPONDENT'S DATE OF BIRTH

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF

Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [If institutionalized, give name and address of institution.]

PETITIONER [Name, address, zip code, and telephone number]

ATTORNEY SELECTED BY RESPONDENT, if any. [Name, address, zip code, telephone number, and juris number]

PSYCHOLOGIST SELECTED BY RESPONDENT, if any. [Name, address, zip code, and telephone number.] C.G.S. 17a-274

CONN. PSYC. LIC. NO.

PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PARENT(S), GUARDIAN(S), CONSERVATOR, CLOSEST RELATIVES [If none, so state,] and INTERESTED PARTIES as defined in Probate Practice Book, Rule 3.1.02. [Give names, addresses, zip codes, and relationships to respondent.]

Note:In addition to the above, the Commissioner of Developmental Services and the Department of Protection and Advocacy must be given notice in all cases. Additional data [on Second Sheet, PC-180] ,if any, is made a part hereof. THE PETITIONER REPRESENTS that: The respondent is now living at the present address written above. The respondent The respondent has is has not received public assistance or institutional care from the State of Connecticut. C.G.S. Ch. 302. is not in an institution for the mentally ill or mentally deficient in this State. C.G.S. §4a-17.

The respondent is a person with mental retardation, AND The respondent is unable to provide for himself or herself at least one of the following: care for personal and mental health needs meals clothing safe shelter or apply.] AND education habilitation protection from harm [Check those that

The respondent has no family or guardian to care for him or her; OR The respondent's family or guardian can no longer provide adequate care for him or her. The respondent is unable to obtain adequate, appropriate services that would enable him or her to receive care, treatment, and education, or habilitation without placement by a court of probate. The respondent is not willing to be placed under the custody and control of the Department of Developmental Services or its agents, or such placement is being sought or contested by the guardian or limited guardian of such person. WHEREFORE, THE PETITIONER REQUESTS that the Court place the respondent with the Department of Developmental Services for The representations contained herein are made under the penalties of false statement.

Date:

............................................................................ Petitioner:

APPLICATION/PLACEMENT OF PERSON WITH MENTAL RETARDATION PC-701

RESET