Section 5122.111 | Affidavit of mental illness.
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.
________________________________________________________________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.
The undersigned represents a trial court or a prosecutor who, as described in division (B)(1)(a)(v)(I) of section 2945.38 of the Revised Code, is alleging that the above said person is a mentally ill person subject to court order: [ ] Yes [ ] No (please specify answer with an X). If Yes, please specify the name and address of the trial court or prosecutor:
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
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