Forensic Evaluation Services-Civil
Acknowledgment:
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I confirm that I have all the required documents ready to submit with this form, as per the instructions, to ensure the processing of my referral request. (If some of the documents are unavailable to you, please note below in additional comments box.)
Date
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/
Month
/
Day
Year
Today's Date
Last Name of the Individual to be Evaluated
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First Name of the Individual to be Evaluated
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Evaluated Individual's Date of Birth
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/
Month
/
Day
Year
Birthdate
Evaluated Individual's Preferred Gender
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Please Select
Female
Male
Transgender Female to Male
Transgender Male to Female
Doesn't identify as F, M, or Transgender
Declined
Unknown
If this referral is associated with other family members or individuals to be evaluated, please indicate those individuals' names here. (If none, type "N/A.")
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Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order)
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Competence to Marry
Competency for Adoption
ORC 2903.211 Menacing by Stalking Evaluation
ORC 2919.271 Domestic Violence/Intimate Partner Violence Evaluation
Risk of Violence/Dangerousness (Adult or Juvenile)
Risk of Sexual Offending (Adult or Juvenile)
ORC 2111.031 Guardianship
ORC 5122.11 Involuntary Civil Commitment
Parent Mental Health/Psychological Evaluation (aka Parental Capacity Evaluation related to condition and its impact on parenting)
Child Custody Evaluation (includes any opinions on parenting time, visitation, and/or custodial rights)
General Mental Health/Psychological Evaluation (Please note if there is a specific type of functioning that needs assessed, such as diagnostic clarification or personality functioning.)
Other
Referring Court or Agency
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Who is ordering this evaluation? (e.g., Judge, Magistrate, or other individual name)
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Who should we contact if we have questions about this referral?
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First Name
Last Name
Referral Source Contact Email Address
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example@example.com
Referral Source Contact Phone Number
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Please enter a valid phone number.
Personal Address of Individual to be Evaluated (Please include their personal address even if they are in a facility.)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the individual to be evaluated residing in a facility at this time?
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Yes
No
Name of Facility/Institution
Phone Number of Individual to be Evaluated
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Entering a valid phone number is REQUIRED, even if they are in a facility.
Attorney Name (If none, type "N/A" in both boxes.)
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First Name
Last Name
Attorney Email Address
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example@example.com
Attorney Phone Number
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Please enter a valid phone number.
Guardian Ad Litem (GAL) (If none, type "N/A" in both boxes.)*
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First Name
Last Name
GAL Email Address
example@example.com
GAL Phone Number
Please enter a valid phone number.
Name and phone number or email address of family member, legal guardian, or other person to contact individual to be evaluated, if applicable.
Please note the ACTUAL hearing date pertaining to the relevant case. (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)
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Docket/Case No.(s)
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Is there anything else you would like us to know about this referral? (e.g., You can add names and contact information for collateral sources or other colleagues, anything not mentioned above that you would like us to know, etc.)
Who will we send the report(s) to? (e.g., judge/magistrate, you as referral contact, etc.)
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Is this a correction to a referral already filed?
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Yes
No
Please upload the required documents. For security reasons, please DO NOT EMAIL documents to individual CDTC staff members. If need be, we can also send you a shared folder link for transfer or accept/pick up recording materials.
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Certification:
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I certify that all information I provide on the referral form is accurate to the best of my knowledge.
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