Skip to main content
Back To Top Top Back To Top
The Legislative Service Commission staff updates the Revised Code on an ongoing basis, as it completes its act review of enacted legislation. Updates may be slower during some times of the year, depending on the volume of enacted legislation.

Section 5122.111 | Affidavit of mental illness.

 
A new version of Section 5122.111 exists that will be effective as of August 3, 2021View New Version

To initiate proceedings for court-ordered treatment of a person under section 5122.11 of the Revised Code, a person or persons shall file an affidavit with the probate court that is identical in form and content to the following:

AFFIDAVIT OF MENTAL ILLNESS

The State of Ohio

____________________ County, ss.

____________________ Court

________________________________________________________________the undersigned, residing at

________________________________________________________________says, that he/she has information to believe or has actual knowledge that

________________________________________________________________ - (Please specify specific category(ies) below with an X.)

[ ] Represents a substantial risk of physical harm to self as manifested by evidence of threats of, or attempts at, suicide or serious self-inflicted bodily harm;

[ ] Represents a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior or evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm or other evidence of present dangerousness;

[ ] Represents a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence of being unable to provide for and of not providing for basic physical needs because of mental illness and that appropriate provision for such needs cannot be made immediately available in the community;

[ ] Would benefit from treatment for mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or the person; or

[ ] Would benefit from treatment as manifested by evidence of behavior that indicates all of the following:

(a) The person is unlikely to survive safely in the community without supervision, based on a clinical determination.

(b) The person has a history of lack of compliance with treatment for mental illness and one of the following applies:

(i) At least twice within the thirty-six months prior to the filing of an affidavit seeking court-ordered treatment of the person under section 5122.111 of the Revised Code, the lack of compliance has been a significant factor in necessitating hospitalization in a hospital or receipt of services in a forensic or other mental health unit of a correctional facility, provided that the thirty-six-month period shall be extended by the length of any hospitalization or incarceration of the person that occurred within the thirty-six-month period.

(ii) Within the forty-eight months prior to the filing of an affidavit seeking court-ordered treatment of the person under section 5122.111 of the Revised Code, the lack of compliance resulted in one or more acts of serious violent behavior toward self or others or threats of, or attempts at, serious physical harm to self or others, provided that the forty-eight-month period shall be extended by the length of any hospitalization or incarceration of the person that occurred within the forty-eight-month period.

(c) The person, as a result of mental illness, is unlikely to voluntarily participate in necessary treatment.

(d) In view of the person's treatment history and current behavior, the person is in need of treatment in order to prevent a relapse or deterioration that would be likely to result in substantial risk of serious harm to the person or others.

________________________________________________________________

(Name of the party filing the affidavit) further says that the facts supporting this belief are as follows: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

These facts being sufficient to indicate probable cause that the above said person is a mentally ill person subject to court order.

Name of Patient's Last Physician or Licensed Clinical Psychologist

________________________________________________________________Address of Patient's Last Physician or Licensed Clinical Psychologist

________________________________________________________________________________________________________________________________

The name and address of respondent's legal guardian, spouse, and adult next of kin are:

Name Kinship Address __________ Legal Guardian __________ - __________ __________ Spouse __________ - __________ __________ Adult Next of Kin __________ - __________ __________ Adult Next of Kin __________ - __________

The following constitutes additional information that may be necessary for the purpose of determining residence:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dated this _____________ day of _______________, 20___

_____________________________

Signature of the party filing - the affidavit

Sworn to before me and signed in my presence on the day and year above dated.

____________________________

Signature of Probate Judge, - Deputy Clerk, or Notary - Public

WAIVER

I, the undersigned party filing the affidavit hereby waive the issuing and service of notice of the hearing on said affidavit, and voluntarily enter my appearance herein.

Dated this _____________ day of _______________, 20___

_____________________________ - Signature of the party filing - the affidavit

Last updated July 6, 2021 at 5:54 PM

Available Versions of this Section