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 additional comments box.)
Date
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/
Month
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Day
Year
Today's Date
Last Name of Individual to be Evaluated
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First Name of Individual to be Evaluated
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Defendant’s Date of Birth
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Month
/
Day
Year
Birthdate
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
Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order): PRE-ADJUDICATION
ORC 2945.371(H)(3) Competence to Stand Trial-Adult
Federal 18 USC 4241 Mental Competency-Adult
ORC 2152.52 Child/Juvenile Competence to Stand Trial
Second Opinion-Competence to Stand Trial (State, Federal, or Juvenile)
ORC 2945.38(B) Competence to Stand Trial Update after undergoing Outpatient Competency Restoration (OCR)
ORC 2152.59 Child/Juvenile Competence to Stand Trial after undergoing Outpatient Competency Attainment (OCA)
ORC 2945.371(H)(4) NGRI-Mental Condition at the Time of the Offense
Federal 18 USC 4242 NGRI-Mental Condition at the Time of the Offense
Second Opinion-NGRI-Mental Condition at the Time of the Offense (State or Federal)
ORC 2901.06/2945.392 Battered Woman/Person Syndrome Evaluation
ORC 2945.39 Incompetent to Stand Trial-Unrestorable-Criminal Jurisdiction (IST-U-CJ)-Least Restrictive Setting-Initial
ORC 2945.39/2945.401 IST-U-CJ-Least Restrictive Setting-Nonsecured Status/Conditional Release Second Opinion
ORC 2945.39/2945.402 IST-U-CJ Conditional Release 2-Year Review
ORC 2152.12 Juvenile Bindover/Transfer to adult jurisdiction
ORC 2951.041 Intervention in Lieu of Conviction
Other
Please select the following evaluation(s) that have been ordered (select all that apply that are noted on the court order): POST-ADJUDICATION
ORC 2945.40 Post-NGRI Evaluation after NGRI Adjudication
Federal 18 USC 4243 Hospitalization of Person Found NGRI
ORC 2945.401 Second Opinion for Nonsecured Status-Least Restrictive Setting-NGRI Acquittee
ORC 2945.402 Conditional Release 6-Month Review-NGRI Acquittee
ORC 2945.402 Conditional Release 2-Year Review-NGRI Acquitee
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
Federal 18 USC 4246 Hospitalization of a Person Due for Release but Suffering from Mental Disease and/or Mental Defect
ORC 2951.03/Criminal Rule 32.2 Mitigation at Presentence Investigation
Mitigation-Advisability of Treatment (State or Federal)
ORC 2947.06 Mitigation-At Penalty Phase/Sentencing
ORC 2967.22 Mitigation-Post-Sentence/Probation/Parole
Classification (or Reclassification) of Sexual Offender (Adult or Juvenile)
ORC 2929.025 Sentencing for Capital Aggravated Murder-Capacity to Conform Conduct
ORC 2949.28 Competency to be Executed
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, Federal, or Juvenile)
Competence to Waive the Right to Counsel/Represent Oneself (State, Federal, or Juvenile)
Competence to Be a Witness (State, Federal, or Juvenile)
Competence to Testify (State, Federal, or Juvenile)
Competence to Plead Guilty (State, Federal, or Juvenile)
Competence to Refuse Insanity Defense & Other Mental State Defenses (State or Federal)
Competence to Proceed in Out-of-State Warrant/Fugitive Proceeding (Adult or Juvenile)
Competence to Proceed in Probation/Community Control Revocation Hearing
ORC 2903.211 Menacing by Stalking Evaluation
ORC 2919.271 Domestic Violence/Intimate Partner Violence Evaluation
Risk of Violence/Dangerousness (State, Federal, or Juvenile)
Risk of Sexual Offending (State, Federal, or Juvenile)
ORC 5122.11 Involuntary Civil Commitment
General Mental Health/Psychological Evaluation
Other
Referring Court or Agency
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Who is ordering this evaluation take place? (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.
Defendant Address (Please include their personal address in the case they are released on bond while detained.)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the defendant residing in a facility at this time?
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Yes
No
Name of Facility/Institution
Defendant Personal Number
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Entering a valid phone number is REQUIRED, even if they are detained, in the case they are released on bond.
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.
Name and phone number or email address of family member, legal guardian, or other person to contact defendant, if applicable.
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.
Please note the ACTUAL hearing date pertaining to relevant cases. (ONLY answer if a hearing date has been scheduled. If none scheduled, note as TBD.)
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Docket/Case No.(s) (Include all those applicable)
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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, probation, 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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