District V Please enable JavaScript in your browser to complete this form.Who is completing this form? *FESC AdminDistrict V or Referring Court or other entityCounty Referring *LorainHuronSenecaWyandotCrawfordRichlandAshlandWayneHardinMarionKnoxHolmesMorrowOther: Out of 422 countiesReferring 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 *Lucas County CCP Hancock County CCP Toledo Muni Court Findlay Muni CourtDefendant's (or youth or Alleged Incompetent) Name *FirstLastDefendant's Date of Birth: mm/dd/yyyy *Docket #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 FESCPHONE 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.EMAIL address for the JAIL, hospital, or DEFENDANT (if not in your jail). Could be relative's information.Who should we contact if we have questions about this referral? *FirstLastTricia HatfieldTitle of Person sending the referral:District V AdminPhone # for CDTC or court personnel in case we need more information419-774-5970Email of person to contact if we have questions *forensics@catalystlifeservices.org Defense Attorney Name (or none) *FirstLastIf none – type 0 or N/A 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. 419-123-4567Comment 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.PLEASE UPLOAD up to 3 documents via this link. Audio/Video are probably too big for this method of transfer Click or drag files to this area to upload. You can upload up to 3 files. 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.For Internal FESC Use OnlyHow will it be paid for?District V – MansfieldFee-for-Service with the courtDistrict V 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?NoYesMessageSubmit referral to FESC
