Fillable Affidavit Of Mental Illness - R.c. 5122.111 Form (Page 2 of 2) in pdf

Affidavit Of Mental Illness - R.c. 5122.111 Form Page 2

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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

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

_________________________________________________________________________________________________

[ ] The Respondent has refused to submit to an examination by a psychiatrist, or by a licensed clinical psychologist and

licensed physician.

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.

________________________________

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

Affidavit Of Mental Illness - R.c. 5122.111 Form Page 2

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