IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY AFFIDAVIT AND PETITION FOR COMMITMENT OF A PERSON ALLEGED TO BE MENTALLY ILL [R.C. Chapter 5122] IN RE: _______________________ ___________________________________________ _________________ Name Address Case Number The State of Ohio, Mahoning County, s.s.: ________________________________________ the undersigned, residing at ____________________ ________________________ , says that he/she has information to believe, or has actual knowledge that ____________________________________ , a resident of __________________ County is mentally ill and subject to hospitalization by Order of the Court in that he/she: * _______ 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 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; or _______ Would benefit from treatment in a hospital for his 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 himself [R.C. §5122.01 (B)]. * (Specify the appropriate category or categories above with an X). ______________________________ further says that the facts supporting this belief are as follows: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ And that such facts are sufficient to indicate probable cause to believe that the above person is a mentally ill person subject to hospitalization by Court Order. American LegalNet, Inc. www.FormsWorkflow.com Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com CASE NO: ________________ That the name and address of Respondent’s legal guardian, spouse and adult next-of-kin are as follows, if applicable (attach a supplemental sheet; if necessary): If the patient was involuntarily admitted under an emergency hospitalization (i.e.”pink slip,” per O.R.C. §5122.10), provide the date of admission. _________________________ If the patient was admitted voluntarily and then later requested release, provide the date upon which the discharge was requested or demanded. _________________________ Further Affiant/Petitioner sayeth naught. Dated_________________________ ______________________________________________ Signature of Affiant/Petitioner _____________________________________________________ Typed or Printed Name _____________________________________________________ Full Address (No. P. O. Boxes) _____________________________________________________ City State Zip Area Code/Phone Sworn to before me and signed in my presence this _____ day of __________________, 20______. _______________________________________ Deputy Clerk/Notary Public RESPONDENT’S PHYSICAL DESCRIPTION: MALE / FEMALE AGE:__________D.O.B.__________________ HEIGHT:________________________________ HAIR COLOR:__________________________ WEIGHT:________________________________ EYE COLOR:___________________________ SOCIAL SECURITY NUMBER:_________________________ OTHER:_________________________ Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com