Fill and Sign the Connecticut Acknowledgmentsindividualus Legal Forms

Certificate of Physician as to Competency of an Individual NOTE: This certificate will be used in legal proceeding. The information this certificate contains must be based on your personal examination of the patient. Please address each issue contained in the certificate including the nature, cause, extent and probable duration of any disability that your patient may have which interferes with his/her ability to make responsible decisions about health care, food, clothing, shelter or property. It is possible that your testimony about this information may be required at a hearing. Thank you for your concern and cooperation. Name of Patient _____________________________________________________ Address of Patient ___________________________________________________ I, __________________ (Name of Physician), located at _______________________ _____________________________________________________ (office address) am a _________ (year) graduate of ____________________________________________ ______________________________________________________________________ (Name and Address of Medical School). The telephone number of the school is _________________. I am licensed to practice medicine/psychology/social work (circle one) in the United States in the following states: (list) __________________________________________ I am Board Certified in (e.g., Psychiatry) __________________. My specialty is (e.g., Psychiatry) ___________________. I have known this patient for (period of time) _____________________________.The history of my involvement with the patient is the following (describe) ___________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. I personally examined __________________ (Name of Patient) on _______________ (date). The examination lasted approximately ____________ (time). I performed or ordered the following tests: (list) ________________________________ ____________________________________________________________________________________________________________________________________________ The patient exhibited the following symptoms:  Physical: (list and describe) _________________________________________  Mental: (list and describe) __________________________________________ Based on tests and my examination of the patient, it is my professional opinion that ___________________________ (Name of Patient):
 has (probable or possible impairmen. .  has other potential impairment(es). I may have additional findings regarding the patient's competency to receive medical care, including the possibility of mental illness. Please provide me with additional information regarding this patient to verify my diagnosis. For evaluation, the patient was administered information. He/she was asked the following questions: a medical statement by the attending physician: I personally examined the patient on: (date). The examination lasted approximately (time) (date). The examination consisted of an evaluation of his/her clinical symptoms. He/she was asked to write an admission or the following written statement for (insert reason for referral of the patient to a mental health provider): (insert address to see the physician). For evaluation, the patient was administered information. He/she was asked the following questions: answer yes or no to the question below: I understand that (fill in your reason for the referral) (insert address to see the physician). Please call my office at to schedule an appointment or consult me or a physician who can provide additional information regarding the patient. I, (name of physician), located at (office address) am a (year) graduate of medical school. I am licensed to practice medicine/psychology/social work (circle three) in (state) (town and county). My specialty is: ( , psychiatry) . I have known (name and address of employee) for (period of time) history of his/her involvement with the patient is the following i, (number of years) experience in treating mental health and/or addiction. I personally examined (name of employee) on: (date). The examination lasted approximately (time). I conducted or ordered the following tests: the patient exhibited the following criteria for mental illness and/or drug addiction:  the patient exhibited symptoms consistent with the requirements for the diagnosis of (fill in the relevant diagnosis, or if no diagnoses were indicated, the current criteria are) psychosis or major depression, or other similar disorder, as determined by an adequate and reliable assessment (I made this determination, or determined that the patient exhibited criteria for the diagnosis based on information available to me at the time of my examination, and I have written this diagnosis on the chart for you to check on a regular basis)  the patient displayed symptoms consistent with the requirements for the diagnosis of bipolar i or bipolar ii disorder, or other similar disorders.