Netcare District V CDTC - Toledo Please enable JavaScript in your browser to complete this form.Date signed ENTRY was received by FESC (D.R.R.)Date you got the signed ENTRY or full packet.IS this a NEW Referral or a CORRECTION/UPDATE to a referral already filed? *This is a NEW referralThis is UPDATED referral InformationIs FESC still waiting on anything that delays assignment?Yes, defendant's contact informationYes, discovery informationNo, we can proceed.County Referring *Other: Outside of counties listedButler CountyClinton CountyHighland CountyPike CountyPreble CountyWarren CountyLickingAshlandFranklinLoganMiamiMontgomery CountyMorrowRichlandSciotoWayneReferring Source *Common Pleas Court - AdultArea Court, Municipal, or County Court (Identify below)Probate 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's OfficePrivate AttorneyChoose Judge, magistrate, or it could be another group.Butler County Common Pleas (BCCP) JudgeOther or Visiting JudgeDaniel HaugheyJ. Gregory HowardJennifer Muench-McElfreshMichael OsterNoah E. PowersKeith M. SpaethGregory S. StephensThese are Butler County CCP JudgesWarren County Common Pleas (WCCP) JudgesOther or Visiting JudgeDonald OdaRobert PeelerTimothy TepeJoseph Kirby (Probate & Juvenile)These are the Warren County Common Pleas JudgesPreble County Common Pleas (PCCP) Judge Other or Visiting JudgeStephen BrunsThere is only really one choice here, please comment somewhere if it's not Judge BrunsPike County Common Pleas (PikeCCP) JudgeOther or Visiting JudgeRobert JunkThere is only really one choice here, please comment somewhere if it's not Judge DeeringLicking County Common Pleas (LCCP) JudgesOther or Visiting JudgeBranstoolMarcelainProbate/Juvenile, Deborah LangThese are the Licking County Common Pleas JudgesClinton County Common Pleas (CCCP) JudgeOther or Visiting JudgeJohn W. RudduckThere is only really one choice here, please comment somewhere if it's not Judge RudduckHighland County Common Pleas (HCCP) JudgeOther or Visiting JudgeRocky CossThere is only really one choice here, please comment somewhere if it's not Judge CossWhich Court, if Area, Municipal or County Court? *Area I - Judge Robert LyonsArea II - Judge Kevin McDonoughArea III - Judge Courtney Caparella-KraemerWarren County County Court - Judge Gary LoxleyWarren County County Court - Judge Robert FischerEaton - Judge Edmund KalilFairfield - Judge Joyce CampbellFranklin - Judge Ronald W. RuppertHamilton - Judge Daniel GattermeyerHillsboro - Judge William C. RandolphLebanon - Judge Martin HubbellMason - D. Andrew BatscheMiddletown - James SherronWilmington - Visiting Judge, McCrackenOther: leave in commentsPlease choose the correct municipality even if that's not the correct judge (so we know what court).Juvenile Court Judges *Butler Juvenile Judge Erik NiehausButler Juvenile Judge Dan PhillipsPreble Juvenile, Jenifer OvermyerWarren Juvenile, Joseph John KirbyLicking Juvenile, Deborah G. LangMiami Juvenile, Scott AltenburgerOther or visiting judgeThese are the Juvenile Court judgesProbate, DR, Other Juvenile Courts, PD or Attorney's Office *Judge John Holcomb (Butler Probate) or Magistrate Maria McBrideJudge Joseph John Kirby (Warren Probate)Judges Carter or Halcomb (Butler DR)Public Defender or Defense AttorneyOTHER Juvenile Court JudgeOTHERJudges or other offices that might refer to us,.More information about outside source making referral:for instance Montgomery County CCP, Hamilton Cty. PD office, or private attorneyDefendant's (or youth or Alleged Incompetent) Name *FirstLastDefendant's Date of Birth: mm/dd/yyyy (D.O.B) *Docket #s - list ALL the docket numbers associated with this ENTRY *Please list the docket number we can use to look up the case on the Clerk of Courts website for the corresponding county.Charge 1, F or M, Severity *Name(s), # of counts, F# or M# (for ex. F-2) and if you can, the ORC #. Example: Murder, F-1, 2903.03 Charge 2, F or M, SeverityName(s), # of counts, F# or M# (for ex. F-2) and if you can, the ORC #. Charges 3, and more F or M, SeverityName(s), # of counts, F# or M# (for ex. F-2) and if you can, the ORC #. 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 (422 or fee) TO STAND TRIAL2945.371 (H) NGRI (422 or fee) - Mental State at the Time of the Charged Offense2945.40 POST-NGRI (422 or fee) after finding of NGRI2945.401Db SECOND OPINION for Non-secured status (422)2951.041 INTERVENTION IN LIEU (fee) - note specifics in next block2901.06/2945.392 BATTERED WOMEN SYNDROME2152.12 JUVENILE BINDOVER (fee)2152.52 JUVENILE COMPETENCY (Fee)Local Rule: JUVENILE PSYCH EVALUATION (fee)Local Rule: JUVENILE RISK ASSESSMENT (fee)OTHER - leave notes in the commentschoose ALL the legal questions listed on the ENTRY or court order.2951.041 Intervention In Lieu of Conviction due to:ILC or Treatment in Lieu of ConvictionPOST CONVICTION or Other - Pursuant to Ohio Revised Code Section: *Check All that Apply2947.06/2967.22 (Fee) MITIGATION of Penalty/Post Sentence - Probation or ParoleLocal Rule: (Fee) JUVENILE PSYCH EVALUATIONLocal Rule: (Fee) JUVENILE RISK ASSESSMENT2950.09 (B)(2)) (Fee) CLASSIFICATION OF SEXUAL PREDATOROTHER: leave notes in commentsChoose ALL the legal questions listed on the court order.OTHER QUESTIONS/ORDERS2111.031 GUARDIANSHIP (fee) Person/EstateOUTPATIENT COMPETENCY RESTORATION (OCR) (grant or fee)RISK OF VIOLENCE/DANGEROUSNESS (fee)Other Competency (fee) to Waive Miranda, Pro Se, be a Witness, or ConsentCivil Commitment Evaluation (fee)Domestic Relations Court (fee)OTHER: leave notes in commentsIF Outpatient Comp Restoration (OCR) - When does that end?The court will have to tell us how LONG we have to restore this person - so the answer here is going to be either an end date or something like "60 days" or "one year."Additional Comments about the referral: (anything you might want the LE or any of us to know)The ACTUAL COURT DATE - Answer only there is an ACTUAL dateThe court needs this report by (mm/dd/yyyy) *If you don't know - say 30 days from referral.Where will the LE see this examiner? *Referring county jail or prisonMeet defendant at FESCCommunity Hospital or Nursing HomeSBH/TVBH/ABH - Ohio MHAS HospitalCourthouse or other officeVIDEOOTHER: DD facility, group home, etc.If it's not a regular place, MAKE A COMMENT about where we will see them.Will we need a DETAIL Officer?NoYesPHONE contact for DEFENDANT or family member or other person to contact defendantIf this defendant gets out of your jail - we will need to track them down. PLEASE GIVE US A PHONE NUMBER.HOW to FIND the defendant: ADDRESS, PHONE, EMAIL (if not in your jail). Could be relative's information.State hospital (SBH)? Or other county jail, or if HOME address street address, city, state, zip Who should we contact if we have questions about this referral? *FirstLastWho will we send this report to? *The judge's last name here is fine.Phone # for court personnel in case we need more informationEmail of person to contact if we have questions *Name@countyProbation.org Defense Attorney Name (or none) *FirstLastIf none - type NONE in both boxes.Defense Attorney Emailfor ex. name@site.orgDefense Attorney Phonefor ex. 5138694014Prosecuting 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. 5138694014*Comment here with anything else that you want us to know.You can add names and contact info for collateral sources or other colleagues, for instance. Or tell us WHERE we will see the defendant.Expected Source of ReimbursementI don't know.422 Grant fundedCourt - Fee for ServiceOCR Grant (only adults)Other funding Source: APS, Netcare, CDTC, etc.422 - are Common Pleas (*Comp, Sanity, Post NGRI, or release from SBH) and must be from one of our 6 counties. COURT Fee for Service are ALL Muni, Area Courts, Probate - 2nd opinion, outside of our counties...all $$ FESC or other agency Internal ID (# - Episode)76513 - episode number(s) Netcare and CDTC have other numerical configurations.Assigned Legal Examiner *Not Yet IdentifiedErinNCSDreyerRKurzhalsALedgeJoyMcO'DOThis field is to trigger sending this information to the Legal Examiner.Date / Time for EvaluationDateTimePhoneReady to SEND to Billing, LE assigned, court and others