ILC Referral Page – Forensic Evaluation Service Center

ILC Referral Form

Referring Agency/Court *

Who should we contact if we have questions about this referral? *

Judge's Name

ILC Defendant to be Evaluated: *

First

Last

Docket #: *

You can add a couple of docket numbers in here, just separate by a comma.

Charge(s)

You can add all the charges in here, just separate by a comma.

Date of OFFENSE

You can add as many dates as you want in here, just separate them by a comma.

Agency ODMH State Form #

If N/A to you, skip this question.

Defendant's Date of Birth *

DD/MM/YYYY

Age in years

Phone # to contact the defendant *

614-444-1212

Email to contact the defendant

name@email.com

How urgently do you need the report? *

Upcoming Court Date

Date

Time

If N/A, leave blank.

Upload any relevant files here:

Drag & Drop Files, Choose Files to Upload

You can upload up to 3 files here. Photos/videos are too large to receive here - please email anything additional to forensicservices@fesc-oh.org

Anything else we need to know?

Please include any other information about this ILC referral that we should know.