Netcare (Columbus) Court Referrals Please enable JavaScript in your browser to complete this form.Who is completing this form? *FESC AdminNetcare AdminCounty Referring *FranklinUnionDelawarePickawayMadisonLickingFairfieldFayetteRossHockingJacksonHardin*Referring Source *Common Pleas Court – AdultMunicipal, or County CourtProbate Court, Common PleasJuvenile Court, Common PleasPublic Defender's OfficeDomestic Relations CourtPrivate AttorneyThis is the PRIMARY contact and court or entity responsible for this case. Who is ordering the evaluation? *JudgeMagistratePublic Defender or Defense AttorneyChoose Judge, magistrate, or it could be another group.TYPE THE JUDGE, Magistrate, or attorney's NAME *Judge Judy Jones, Magistrate Minnie Mouse, Attorney Adam Ant, or Lucas County Public Defender’s OfficeTYPE THE County Name and the type of Court *Franklin County CCP Madison County CCP Columbus Muni Court Dublin Muni Court COPY it from the letterhead for the referralDefendant's (or youth or Alleged Incompetent) Name *FirstLast(D.O.B.) Defendant's Date of Birth: mm/dd/yyyy *GenderDon't KnowMaleFemaleTransgender Male to FemaleTransgender Female to MaleDoesn't Identify to anyDeclinedDocket #Please list the docket number we can use to look up the case on the Clerk of Courts website for the corresponding county.Additional Docket #s (if applicable)List as many here, as needed.Present Charge(s) *Name(s), # of counts, F# or M# (for ex. F-2)Date of the offense (mm/dd/yyyy)You can only put one of the dates in here, if there are other dates, just put those in the comments. The date of the offense helps us get more accurate information.PRE-CONVICTION QUESTIONS Pursuant to Ohio Revised Code Section: *CHECK ALL THAT APPLY2945.371(H) & 2945.38 COMPETENCY TO STAND TRIAL2945.371 (H) NGRI – Mental State at the Time of the Charged Offense2945.40 POST-NGRI, after finding of NGRI2945.401Db SECOND OPINION for Non-secured status2951.041 INTERVENTION IN LIEU2901.06/2945.392 BATTERED WOMEN SYNDROME2152.12 JUVENILE BINDOVER2152.52 JUVENILE COMPETENCYLocal Rule: JUVENILE PSYCH EVALUATIONLocal Rule: JUVENILE RISK ASSESSMENTOTHER – leave notes in the commentsPOST CONVICTION or Other – Pursuant to Ohio Revised Code Section: *Check All that Apply2947.06/2967.22 MITIGATION of Penalty/Post Sentence – Probation or ParoleLocal Rule: JUVENILE PSYCH EVALUATIONLocal Rule: JUVENILE RISK ASSESSMENT2950.09 (B)(2)) CLASSIFICATION OF SEXUAL PREDATOROTHER: leave notes in commentsOTHER QUESTIONS/ORDERS2111.031 GUARDIANSHIP Person/EstateRISK OF VIOLENCE/DANGEROUSNESSOther Competency to Waive Miranda, Pro Se, be a Witness, or ConsentCivil Commitment EvaluationDomestic Relations CourtOTHER: leave notes in commentsAdditional Comments about the referral: (anything you might want us to know)The ACTUAL COURT DATE – Answer only there is an ACTUAL datePlease allow 30 days for us to complete this work. If you cannot, we will let you know if we need more time than is allotted and ask for a continuance. The court needs this report by (mm/dd/yyyy) *We will provide reports to the court at least one business day ahead of court, unless other arrangements have been made.How will we interview the defendant? *VIDEOFACE to FACE in county jail – see commentsDefendant will be transferred to FESCNAME of Family Member, PARENT, Legal GuardianPHONE contact for family member or other person to contact defendant or to get collateralphone number for the family members/parent/legal guardian.EMAIL address or mailing address for Legal Guardian/Parent/Family MemberWho should we contact if we have questions about this referral? *FirstLastNick Williams nwilliams@netcareaccess.orgTitle of Person sending the referral:Netcare AdminPhone # for court personnel in case we need more information614-278-0200Email of person to contact if we have questions *nwilliams@netcareaccess.orgDefense Attorney Name (or none) *FirstLastIf none – type NONE in both boxes.Defense Attorney Emailfor ex. name@site.orgDefense Attorney Phonefor ex. (614) 525-3194 – Franklin County PD’s OfficeProsecuting Attorney Name (or contact for prosecutor's office)FirstLastif none – type none in both boxes.Prosecuting Attorney Emailfor ex. name@site.orgProsecuting Attorney Phonefor ex. (614) 525-3555 Franklin Prosecutor’s OfficeComment here with anything else that you want us to know.Please add names and contact info for collateral sources or other colleagues, for instance.PLEASE UPLOAD up to 3 documents via this link. Include Legal Guardianship papers if available Click or drag files to this area to upload. You can upload up to 3 files. Video files will be too big. We can send you a shared folder link for transfer or accept/pick up recording materials. We can take up to 3 files through here, and you can submit more via the short form below or email or fax 513-867-5868I have attached files to this referralYES – see attachedNo, I will email them to forensicservices@fesc-oh.orgNo, I will contact you at 513-869-2010 to make arrangements.Link to Folder for records, testing, discovery, etc.For Internal FESC Use OnlyHow will it be paid for?Other Funding Source: Netcare – (Columbus)Netcare Internal ID # – EpisodeAssigned Legal Examiner Not Yet IdentifiedErinNCSDreyerRKurzhalsALedgeJoyMcJROThis internal (only) field is to trigger sending this information to the Legal Examiner.Date / Time for EvaluationDateTimeIS this a CORRECTION to a referral already filed?NoYesEducation LevelUnknownLevel 1-11High School Diploma or EquivalentLess than First GradeTrade Tech School – Post HSSome College2-year degree4-year degreeMessageSubmit referral to FESC