Affidavit Of Mental Illness {6.0}

PROBATE COURT OF MAHONING COUNTY, OHIO HON. ROBERT N. RUSU, JR., JUDGE IN THE MATTER OF ______________________________________________________________ CASE NO. ______________________________________________________________________ AFFIDAVIT OF MENTAL ILLNESS R.C. 5122.111 __________________________________________________________________________, 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 not providing 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 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 (b) The person has 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 5122.11 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. Within the forty-eight months prior to the filing of an affidavit seeking court-ordered treatment of the person under section 5122.11 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. [] [] [] [] (ii) The person, as a result of mental illness, is unlikely to voluntarily participate in necessary treatment. In view of the persons 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. _____________________________________________ further says that the facts supporting this belief are as follows: _________________________________________________________________________________________________ _________________________________________________________________________________________________ (c) (d) _________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 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 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 _______________, 201___. ________________________________ Signature of the Party Filing the Affidavit Sworn to before me and signed in my presence on the day and year above dated. Address ________________________________ Probate Judge ________________________________ Deputy Clerk 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 _______________, 201___. ______________________________ Signature of Party Filing Affidavit American LegalNet, Inc. www.FormsWorkFlow.com