Commitment Under Psychologist’s Emergency Certificate: 

A licensed psychologist may order a person transported to a general hospital for examination and possible emergency confinement when he has reasonable cause to believe that the person has psychiatric disabilities and is dangerous to himself or others or gravely disabled and in need of immediate care an treatment.  The psychologist can issue a written emergency certificate authorizing and directing that the person be taken to a general hospital for purposes of a medical examination.  He must be examined within 24 hours and released within 72 hours, unless detained and committed under the certificate (CGS Sec. 17a-503(c)).

Psychologist Emergency Examination Request (MHCC-1A)

Completed forms may be emailed to EBPadmin@ct.gov.