District V Referral Form The information submitted through this form is not confidential. Should you have any concerns about submitting any specific data, please contact the Forensic Diagnostic Center at 419-774-5970. New Referral Information County Referring —Please choose an option—AshlandCrawfordHardinHolmesHuronKnoxLorainMarionMorrowRichlandSenecaWayneWyandot Referring Source —Please choose an option—Common Pleas Court – AdultCommon Pleas Court – JuvenileMunicipal CourtOther Details about "Other" Referring Party Referring Judge/Magistrate Person Completing Form Name Title Phone Number Email Court Case and Defendant/Examinee Information Docket Numbers Defendant's/Examinee's Name (First and Last Names, Middle and Suffix optional) Defendant's/Examinee's Date Of Birth (XX/XX/XXXX) Present Charge(s) May the defendant/examinee be eligible for the death penalty? YesNo Is the defendant/examinee's first language English? YesNo Please specify other language: Does the defendant/examinee need any accomodations? YesNo Please describe: Does the defendant/examinee have a legal guardian? YesNo Guardian's Full Name: Guardian's Phone Number: Guardian's Email Address: Any additional information we should know about the defendant/examinee? Leave blank if none. The court would like this report by (MM/DD/YYYY): Please allow for 30 days for us to complete the evaluation (45 for juvenile referrals). If there is a different date the court would like the evaluation completed, please note it below and we will do our best to accommodate. If we cannot do so for any reason, we will ask for a continuance. Has an upcoming court date already been scheduled? YesNo Where is the defendant/examinee currently placed/located? In our county jailIn another county jailIn prison (ODRC)In a psychiatric hospitalIn a group homeAt a personal residenceHomelessOther Please specify the Jail, Prison, Hospital, group home (location and phone), or home address. Is there anyone in particular we should contact for the evaluation? YesNo If yes, please specify: Name Relationship Phone Number ORC Referral Questions (Check all that Apply) 2945.371(H)(3) Competency to Stand Trial: Evaluation of a defendant’s present mental condition and whether s/he understands the nature and proceedings against him/her and can assist in his/her defense2945.371(H)(4) Mental Condition at the Time of Offense Charged (Not Guilty by Reason of Insanity: NGRI): Evaluation of a defendant’s mental condition at the time of the offense charged and whether, due to a severe mental disease or defect, he/she did not know the wrongfulness of his/her acts charged2945.40 Procedure Upon Acquittal by Reason of Insanity (Post-NGRI): Following an adjudication of not guilty by reason of insanity, evaluation to determine if defendant is a mentally ill person subject to court order or a person with an intellectual disability subject to institutionalization by court order2945.39 (A)(2)(b) Expiration of the Maximum Time for Treatment for Incompetency (Post-Incompetency to Stand Trial Unrestorable (Post-ISTU) or Criminal Jurisdiction): Following a finding of incompetent to stand trial unrestorable (or that there is not a substantial probability h/she will be restored), evaluation to determine if defendant is a mentally ill person subject to court order or a person with an intellectual disability subject to institutionalization by court order2945.401(D)(b) Nonsecured Status (Second Opinion): Evaluations to approve nonsecured status or termination of commitment of those committed and adjudicated as incompetent to stand trial unrestorable or not guilty by reason of insanity2951.041 Intervention in Lieu of Conviction: Evaluation to determine if drug or alcohol use, mental illness, intellectual disability, or status as a victim of trafficking in persons, was a factor leading to the criminal offense(s)2947.06 Mitigation of Penalty: Evaluations of a defendant post-adjudication for the trial court to determine the disposition of a case2951.03 Presentence Investigation Reports of those Guilty of a Felony: Evaluations of a defendant adjudicated guilty of a felony2152.52 Juvenile Competency to Stand Trial: Evaluation of whether a child, due to mental illness, intellectual disability, developmental disability, or otherwise, is incapable of understanding the nature and objective of the proceedings or of assisting in child's defense2152.12 (Rule 30) Transfer of Juvenile to Adult Court: Evaluation of a child to determine amenability to juvenile rehabilitation and determination of factors in favor of, or against, transfer2950.09(B)(2) Classification As Sexual Predator: Evaluation to determine as to whether the offender or delinquent child is a sexual predator Other Referral Questions (check all that apply) Competency to Waive Miranda RightsCompetency to Proceed Pro SeCompetency to Testify as a WitnessRisk of Sexual Violence or DangerousnessRisk of Violence or DangerousnessOther If "Other", please specify what the court would like to be evaluated: Defense Attorney Information If not proceeding pro se, please check here. Not Proceeding Pro Se Name (First and Last) Phone Number Email Prosecuting Attorney Information Name (First and Last) Phone Number Email I acknowledge that the information submitted through this form is not confidential Δ