PSYCHOLOGIST EMERGENCY EXAMINATION REQUEST ... - CT.gov - ct 2026

1. Click ‘Get Form’ to open the PSYCHOLOGIST EMERGENCY EXAMINATION REQUEST in our editor.
2. Begin by entering the PERSON’S NAME at the top of the form. Ensure accuracy as this is crucial for identification.
3. Fill in the DIRECTIVE AND AUTHORIZATION section, specifying the town in Connecticut where the request is being made.
4. In the AUTHORIZED AND DIRECTED section, indicate the name of the General Hospital where you are directing the individual for examination.
5. Complete the SIGNATURE section with your name, CT LICENSE NUMBER, and BUSINESS ADDRESS. Don’t forget to include your DATE OF REQUEST and TELEPHONE NUMBER.
6. Provide details about the PERSON TO BE EXAMINED, including their PRESENT ADDRESS, SEX, BIRTH DATE, MARITAL STATUS, and SOC. SEC. NO.
7. Document any relevant HISTORY OF PRESENT CONDITION and OTHER PERTINENT HISTORY that may assist in their evaluation.
8. Finally, ensure that both copies of the form are signed and dated appropriately before submission.

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