Fillable Affidavit Of Mental Illness - R.c. 5122.111 Form printable pdf download

PROBATE COURT OF TRUMBULL COUNTY, OHIO

JAMES A. FREDERICKA, 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 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 history of lack of compliance with treatment for mental illness and at least 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.

(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.

_____________________________________________ further says that the facts supporting this belief are as follows:

_________________________________________________________________________________________________

Affidavit Of Mental Illness - R.c. 5122.111 Form

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