Forensic Evaluation Services-Criminal
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 take place? (e.g., Judge, Magistrate, or other individual name)
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First Name of individual to be evaluated
Last Name of individual to be evaluated
Defendant Number
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Please enter a valid phone number.
Defendant’s Date of Birth
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Month
-
Day
Year
Date
Defendant'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
Where is the defendant residing 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.
Docket/Case No.(s)(Include all those applicable)
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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): PRE-CONVICTION
ORC 2945.371(H)(3) Competency to Stand Trial-Adult
Federal 18 USC 4241 Mental Competency-Adult
ORC 2152.52 Child/Juvenile Competency to Stand Trial
Second Opinion-Competency to Stand Trial
ORC 2945.38(B) Competency to Stand Trial Update after undergoing Outpatient Competency Restoration
ORC 2945.371(H)(4) NGRI-Mental Condition at the Time of the Offense
ORC 2945.40 Post-NGRI Evaluation after NGRI adjudication
Federal 18 USC 4242 NGRI-Mental Condition at the Time of the Offense
Federal 18 USC 4243 Hospitalization of Person Found NGRI
Second Opinion-NGRI-Mental Condition at the Time of the Offense
ORC 2901.06/2945.392 Battered Woman Syndrome Evaluation
ORC 2945.402 Second Opinion for Non-Secured Status-Conditional Release
ORC 2945.39 Incompetent to Stand Trial-Unrestorable-Court Jurisdiction (IST-U-CJ)
ORC 2152.12 Juvenile Bindover/Transfer to adult jurisdiction
Other
Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order): POST-CONVICTION
ORC 2929.025 Sentencing for Capital Aggravated Murder-Capacity to Conform Conduct
ORC 2949.28 Competency to be Executed
Classification of Sexual Predator
ORC 2951.03/Criminal Rule 32.2 Mitigation at Presentence Investigation
Mitigation-Advisability of Treatment (state or Federal)
ORC 2951.041 Intervention in Lieu of Conviction
ORC 2947.06 Mitigation-At Penalty Phase/Sentencing
Federal 18 USC 4244 Hospitalization of Convicted Person Suffering from Mental Disease and/or Mental Defect
Federal 18 USC 4245 Hospitalization of Imprisoned Person Suffering from Mental Disease and/or Mental Defect
ORC 2967.22 Mitigation-Post-Sentence/Probation/Parole
Federal 18 USC 4246 Hospitalization of a Person Due for Release but Suffering from Mental Disease and/or Mental Defect
ORC 2945.401 Second Opinion for nonsecured Status
Other
Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order): OTHER TYPES OF EVALUATIONS
Competence to Waive Miranda Rights (state or Federal)
Competence to Waive the Right to Counsel/Represent Oneself (state or Federal)
Competence to Be a Witness (state or Federal)
Competence to Testify (state or Federal)
Competence to Plead Guilty (state or Federal)
Competence to Refuse Insanity Defense & Other Mental State Defenses (state or Federal)
Competence to proceed in Out-of-State Warrant/Fugitive Proceeding
Competence to Proceed in Probation/Community Control Revocation Hearing
ORC 2903.211 Menacing by Stalking Evaluation
ORC 2919.271 Domestic Violence Evaluation
Risk of Violence/Dangerousness (state or Federal)
Risk of Sexual Offending (state or Federal)
ORC 5122.11 Involuntary Civil Commitment
General Mental Health/Psychological Evaluation
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 pertaining. (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)
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Who will we send the report(s) to? (e.g., judge, you as referral contact, probation, etc.)
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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.
Prosecuting Attorney Name
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First Name
Last Name
Prosecuting Attorney Email Address
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example@example.com
Prosecuting Attorney Phone Number
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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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