Court Referral – Forensic Evaluation Service Center

Referral Form For Courts & Agencies
Referring Cases to FESC

County Referring *

Referring Source *

Name of person we should contact if we have questions about this referral *

First

Last

Email of person to contact if we have questions *

A copy of this referral (once submitted) will be sent to this email address.

Who is ordering the evaluation? *

Defendant's (or youth or Alleged Incompetent) Name *

First

Last

Defendant's Date of Birth: mm/dd/yyyy *

Docket #(s)

Please list the docket number we can use to look up the case(s) on the Clerk of Courts website for the corresponding county.

Present Charge(s) *

Name(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.

POST CONVICTION or Other - Pursuant to Ohio Revised Code Section: *Check All that Apply

2947.06/2967.22 MITIGATION of Penalty/Post Sentence - Probation or Parole
Local Rule: JUVENILE PSYCH EVALUATION
Local Rule: JUVENILE RISK ASSESSMENT
2950.09 (B)(2)) CLASSIFICATION OF SEXUAL PREDATOR
OTHER: leave notes in comments

Choose ALL the legal questions listed on the court order.

OTHER QUESTIONS/ORDERS

2111.031 GUARDIANSHIP Person/Estate
OUTPATIENT COMPETENCY RESTORATION (OCR)
RISK OF VIOLENCE/DANGEROUSNESS
Other Competency to Waive Miranda, Pro Se, be a Witness, or Consent
Civil Commitment Evaluation
Domestic Relations Court
Advisability of Treatment
OTHER: leave notes in comments

The COURT DATE - Please answer only if there is an actual date

If less than 30 days, please call and discuss the timing allowance. 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.

Phone # for court personnel in case we need more information

Where is the defendant located? (choose one) *

In our county jail
In a different county jail from the referring county
Out in the community

If he/she is not incarcerated YOU MUST GIVE US A PHONE NUMBER to find this defendant.

PHONE number for defendant, family member, or other person to contact defendant

If 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. Could be relative's information.

State hospital (SBH)?, other county jail, etc. If providing HOME address, include street address, city, state, & zip.

Who will we send this report to? *

The judge's last name here is fine.

Defense Attorney Name (or none) *

First

Last

If none - type NONE in both boxes.

Defense Attorney Email

for ex. name@site.org

Defense Attorney Phone

for ex. 5138694014

Prosecuting Attorney Name (or contact for prosecutor's office)

First

Last

if none - type none in both boxes.

Prosecuting Attorney Email

for ex. name@site.org

Prosecuting Attorney Phone

for ex. 5138694014

If this is the court's 1st time working with FESC, please provide Billing Contact info (name & email):

This is who we should contact regarding invoice delivery or other misc. billing inquiries. You can also email billing@fesc-oh.org with any questions or updates.

Comment here with anything additional that you want us to know about this referral.

You can add names and contact info for collateral sources or other colleagues, for instance.

Are you attaching files to this referral?

Yes, see attached
No, I will email them to forensicservices@fesc-oh.org
No, I will call your clerk (513-869-2010) to make arrangements

Upload up to 3 documents via this link. (Audio/Video are too big for this method of transfer.)

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

We can take up to 3 files through here. You can submit more via email to forensicservices@fesc-oh.org OR by using this link on our website: fesc-oh.org/portal/ OR by mail OR by fax.

Phone

Referral Form For Courts & Agencies Referring Cases to FESC

Referral Form For Courts & Agencies
Referring Cases to FESC