Psychologists Report Placement Of Person With Intellectual Disability{PC-772}

CONNECTICUT PROBATE COURTS Psychologist222s Report/Placement of Person with Intellectual Disability with the Department of Developmental Services PC - 772 RE V. 10/18 CONFIDENTIAL Psychologist222s Report/Placement of Person with Intellectual Disability with the Department of Developmental Services PC-772 RECEIVED : Instructions: 1) A Connecticut - licensed psychologist may use this report to provide information that will be used by the court to determine whether the respondent will be placed in the custody and control of theDepartment of Developmental Services for placement in an appropriate setting. 6) Type or pri nt the form in ink. Use an additional sheet, or PC- 180, if more space is needed. Probate Court Name District Number In the atter of Hereinafter referred to as the respondent Respondent222s Date of Birth Psychologist (Name, address and telephone number) Date of Exam Is the respondent a person with intellectual disability as defined in C.G.S. section 1-1g? Yes No Please explain the results of any psychological assessment given within the past year and identify all standard assessments used. American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Psychologist222s Report/Placement of Person with Intellectual Disability with the Department of Developmental Services PC - 772 RE V. 10/18 CONFIDENTIAL Psychologist222s Report/Placement of Person with Intellectual Disability with the Department of Developmental Services PC-772 What were the results of your interview with, or your observation of, the respondent? Please provide an evaluation of the adaptive behavior of the respondent, including a statement of the respondent222s needs. Attorney(s) of Record (Name, address, telephone number and Juris number) Signature of Psychologist Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com