Get Psychologist Emergency Examination Request ... - Ct.gov - Ct

Completing the psychologist emergency examination request form is essential for ensuring the appropriate care for individuals in need. This guide provides clear, step-by-step instructions to help you accurately fill out the form and ensure smooth processing.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access and open the PSYCHOLOGIST EMERGENCY EXAMINATION REQUEST in your preferred editor.
2. Begin by filling in the person's name at the top of the form. Ensure that the name is spelled correctly to avoid any confusion.
3. Next, indicate the directive and authorization by completing the section that acknowledges that you have reasonable cause to believe the named person is in need of immediate care and treatment.
4. Fill in the appropriate town in Connecticut where you are located to provide context to the request.
5. Complete the section with the name of the general hospital to which the person will be taken for examination.
6. Sign the form in the designated area for the requesting psychologist. Include your CT license number, business address, telephone number, and the date of the request.
7. Confirm that all details regarding the person to be examined are filled out, including their present address, sex, birth date, marital status, veteran status, and social security number.
8. Provide information about the nearest relative, friend, or guardian, including their address and telephone number, and indicate whether they have been notified of this request.
9. Document the history of the present condition and the reason for the examination request thoroughly to provide clear context for the need for examination.
10. Complete the section for other pertinent history, noting any previous hospitalizations, treatments, suicide attempts, or medications related to the individual.
11. Finally, review all the details for accuracy, save your changes, then download, print, or share the completed form as necessary.

Complete your documents online today to ensure timely processing and care.