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 "Other Comments")
Date
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Month
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Day
Year
Date
Referring Court or Agency
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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.
Who is ordering this evaluation? (e.g., Judge, Magistrate, or other individual name)
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First Name of the Individual to be Evaluated
Last Name of the Individual to be Evaluated
Evaluated Individual's Date of Birth
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Month
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Day
Year
Date
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
Docket/Case No.(s)
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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 Evaluation
Risk of Violence/Dangerousness
Risk of Sexual Offending
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 the if there is a specific type of functioning that needs assessed, such asdiagnostic clarification or personality functioning)
Other
Is there anything else you would like us to know about this referral? (e.g., anything not mentioned above that you would like us to know)
Please note the ACTUAL hearing date (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)
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Name of who we will send the report(s) to? (e.g., judge, you as referral contact, probation, etc.)
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Where is the individual to be evaluated located at this time?
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Community?
Facility?
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In a facility/institution (note name of facility in text box)
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Facility phone number
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Please enter a valid phone number.
Individual to be evaluated phone number
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Please enter a valid phone number.
Name and phone number or email of family member, guardian, or other person to contact defendant, if applicable.
Defense Attorney Name (if none, type "N/A" in both boxes)
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First Name
Last Name
Defense Attorney Email Address
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example@example.com
Defense 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 Attorney Phone Number
Please enter a valid phone number.
Other Comments about anything else you want us to know (e.g., You can add names and contact info for collateral sources or other colleagues.)
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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