Form MHCC-1A "Psychologist Emergency Examination Request" - Connecticut

Form MHCC-1A Printable Pdf
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What Is Form MHCC-1A?

This is a legal form that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2004;
  • The latest edition provided by the Connecticut Department of Mental Health & Addiction Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MHCC-1A by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.

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Download Form MHCC-1A "Psychologist Emergency Examination Request" - Connecticut

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PSYCHOLOGIST EMERGENCY EXAMINATION REQUEST
333
MHCC-1A Rev. 6/04
State of Connecticut
Department of Mental Health and Addiction Services
th
P.O. Box 341431, 410 Capitol Avenue, 4
Floor
Hartford, CT 06134
1. This form must be completed in DUPLICATE and signed by the psychologist making the request.
2. One copy must be left with the hospital and one copy returned to the psychologist.
PERSON’S NAME:
OF: (Town in Connecticut)
DIRECTIVE
AND
To any proper authority:
AUTHORIZATION
As a psychologist licensed in the State of Connecticut, I have reasonable cause to believe that the above-named person is psychiatrically
disabled and dangerous to himself or herself or others, or gravely disabled, and in need of immediate care and treatment.
C.G.S. 17a-503©
You are therefore AUTHORIZED AND DIRECTED to take said person to:_______________________________________________________,
a General Hospital, for purposes of a medical examination.
SIGNED: (Requesting Psychologist)
CT LICENSE NUMBER
DATE OF REQUEST
BUSINESS ADDRESS: (No. & Street, city, state, zip code)
TELEPHONE NUMBER
By virtue of the foregoing directive, I transported the above-named person to the designated General Hospital, and there entrusted said person to a
duty authorized representative of said hospital.
RETURN
SIGNATURE: (Proper Authority)
DATE
TIME
am
pm
HOSPITAL NAME:
RECEIVED BY: (Authorized hospital representative)
PERSON TO BE EXAMINED: (Name)
PRESENT ADDRESS:
SEX
BIRTH DATE
MARITAL STATUS
VETERAN
SOC. SEC. NO.
RELIGION
TO:
HOSPITAL
EMERGENCY
NEAREST RELATIVE/FRIEND/GUARDIAN KNOWN TO THE UNDERSIGNED
RELATIONSHIP
TELEPHONE NO.
ROOM
ADDRESS OF RELATIVE (etc.)
The relative named above HAS
HAS NOT
been notified of this request.
HISTORY OF PRESENT CONDITION AND REASON FOR EXAMINATION REQUEST:
OTHER PERTINENT HISTORY: (Previous hospitalizations, treatment, suicide attempts, medications, etc.)
SIGNED: (Requesting Psychologist)
DATE OF SIGNATURE
FOR
CASE NUMBER
DISPOSITION
ADMISSION DATE & TIME
ADMITTED BY
HOSPITAL
am
USE
pm
ONLY
PSYCHOLOGIST EMERGENCY EXAMINATION REQUEST
333
MHCC-1A Rev. 6/04
State of Connecticut
Department of Mental Health and Addiction Services
th
P.O. Box 341431, 410 Capitol Avenue, 4
Floor
Hartford, CT 06134
1. This form must be completed in DUPLICATE and signed by the psychologist making the request.
2. One copy must be left with the hospital and one copy returned to the psychologist.
PERSON’S NAME:
OF: (Town in Connecticut)
DIRECTIVE
AND
To any proper authority:
AUTHORIZATION
As a psychologist licensed in the State of Connecticut, I have reasonable cause to believe that the above-named person is psychiatrically
disabled and dangerous to himself or herself or others, or gravely disabled, and in need of immediate care and treatment.
C.G.S. 17a-503©
You are therefore AUTHORIZED AND DIRECTED to take said person to:_______________________________________________________,
a General Hospital, for purposes of a medical examination.
SIGNED: (Requesting Psychologist)
CT LICENSE NUMBER
DATE OF REQUEST
BUSINESS ADDRESS: (No. & Street, city, state, zip code)
TELEPHONE NUMBER
By virtue of the foregoing directive, I transported the above-named person to the designated General Hospital, and there entrusted said person to a
duty authorized representative of said hospital.
RETURN
SIGNATURE: (Proper Authority)
DATE
TIME
am
pm
HOSPITAL NAME:
RECEIVED BY: (Authorized hospital representative)
PERSON TO BE EXAMINED: (Name)
PRESENT ADDRESS:
SEX
BIRTH DATE
MARITAL STATUS
VETERAN
SOC. SEC. NO.
RELIGION
TO:
HOSPITAL
EMERGENCY
NEAREST RELATIVE/FRIEND/GUARDIAN KNOWN TO THE UNDERSIGNED
RELATIONSHIP
TELEPHONE NO.
ROOM
ADDRESS OF RELATIVE (etc.)
The relative named above HAS
HAS NOT
been notified of this request.
HISTORY OF PRESENT CONDITION AND REASON FOR EXAMINATION REQUEST:
OTHER PERTINENT HISTORY: (Previous hospitalizations, treatment, suicide attempts, medications, etc.)
SIGNED: (Requesting Psychologist)
DATE OF SIGNATURE
FOR
CASE NUMBER
DISPOSITION
ADMISSION DATE & TIME
ADMITTED BY
HOSPITAL
am
USE
pm
ONLY
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