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

    Person Completing Form

    Phone Number

    Court Case and Defendant/Examinee Information

    May the defendant/examinee be eligible for the death penalty?

    Is the defendant/examinee's first language English?

    Does the defendant/examinee need any accomodations?

    Does the defendant/examinee have a legal guardian?

    Has an upcoming court date already been scheduled?

    Where is the defendant/examinee currently placed/located?

    Is there anyone in particular we should contact for the evaluation?

    If yes, please specify:

    ORC Referral Questions (Check all that Apply)

    Other Referral Questions (check all that apply)

    Defense Attorney Information

    If not proceeding pro se, please check here.

    Prosecuting Attorney Information