ILC Referral Page – Forensic Evaluation Service Center

Agency/Court TO BE BILLED for evaluation *

ILC Defendant to be Evaluated: *

First

Last

Docket #:

You can add a couple of docket numbers in here, just separate by a comma.

Charge(s)

You can add all the charges in here, just separate by a comma.

Date of OFFENSE

You can only add as many dates as you want in here, just separate them by a comma.

Judge's Name

Agency ODMH State Form#

This is the Agency # on the ENTRY or if not from Netcare this will be the agency state form #. It's not required to schedule.

Defendant's Date of Birth *

DD/MM/YYYY

Age in years

Phone # to contact the defendant to be evaluated *

614-444-1212

Email for defendant

name@email.com

Date FESC received referral from Netcare

Date

Time

This can be a ballpark, but I need a date in here.

Report Needed BY - category

Report target due date (to be sent to agency)

Unless we KNOW there is a court date. Set this date 15 days after the initial interview - so it is a suggestion for tracking purposes.

Assigned LE *

Assigned Assistant

If there is a student assigned to participate in the ILC, choose the correct student and the face sheet will be sent to that student.

VENUE of INTERVIEW *

Choose one, please.

Date / Time of VIDEO or In-Person Interview

Date

Time