PC-MI-50.2 (Rev. 3-2015) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF CASE NO. M AFFIDAVIT OF MENTAL ILLNESS [R.C. 5122.111] The State of Ohio, Franklin County, s.s. the undersigned, residing at says that he/she has information to believe, or has actual knowledge that ill, and because of the person's illness: , a resident of (Please specify specific category(ies) below with an X) County is mentally 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, 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 that the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those 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 NOTE: An individual who meets only the criteria described in the box below is not subject to hospitalization. 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. FRANKLIN COUNTY FORM 50.2 - AFFIDAVIT OF MENTAL ILLNESS (PAGE 1) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. (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. further says that the facts supporting this belief are as follows: (be specific with facts substantiating diagnosis) These facts being sufficient to indicate probable cause that the above person is a mentally ill person subject to court order. FRANKLIN COUNTY FORM 50.2 - AFFIDAVIT OF MENTAL ILLNESS (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 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 Address The following constitutes additional information that may be necessary for the purpose of determining residence: Date Affiant Sworn to and subscribed before me a Notary Public or Deputy Clerk of the Probate Court on this , 20 . day of Notary Public/Deputy Clerk WAIVER I, the undersigned affiant, hereby waive the issuing and service of Notice of Hearing on this Affidavit, and voluntarily enter my appearance herein. Date Affiant FRANKLIN COUNTY FORM 50.2 - AFFIDAVIT OF MENTAL ILLNESS (PAGE 3) American LegalNet, Inc. www.FormsWorkFlow.com