FACE SHEET DATA ENTRY – Forensic Evaluation Service Center

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 referral
This is UPDATED referral Information

County Referring *

Referring Source *

This is the PRIMARY contact and court or entity responsible for this case.

Who is ordering the evaluation? *

Choose Judge, magistrate, or it could be another group.

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

First

Last

Defendant'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, Severity

Name(s), # of counts, F# or M# (for ex. F-2) and if you can, the ORC #.

Charges 3, and more F or M, Severity

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 (Fee) MITIGATION of Penalty/Post Sentence - Probation or Parole
Local Rule: (Fee) JUVENILE PSYCH EVALUATION
Local Rule: (Fee) JUVENILE RISK ASSESSMENT
2950.09 (B)(2)) (Fee) 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 (fee) Person/Estate
OUTPATIENT COMPETENCY RESTORATION (OCR) (grant or fee)
RISK OF VIOLENCE/DANGEROUSNESS (fee)
Other Competency (fee) to Waive Miranda, Pro Se, be a Witness, or Consent
Civil Commitment Evaluation (fee)
Domestic Relations Court (fee)
OTHER: leave notes in comments

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 date

The 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? *

If it's not a regular place, MAKE A COMMENT about where we will see them.

PHONE contact for DEFENDANT or 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.

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

First

Last

Who will we send this report to? *

The judge's last name here is fine.

Phone # for court personnel in case we need more information

Email of person to contact if we have questions *

Name@countyProbation.org

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

*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 Reimbursement

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 *

This field is to trigger sending this information to the Legal Examiner.

Date / Time for Evaluation

Date

Time

Website