Ohio Code 5122.111 – Affidavit of mental illness
To initiate proceedings for court-ordered treatment of a person under section 5122.11 of the Revised Code, a person or persons shall file an affidavit with the probate court that is identical in form and content to the following:
Terms Used In Ohio Code 5122.111
- Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
- Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
- Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
- Court: means the probate division of the court of common pleas. See Ohio Code 5122.01
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Hospital: means a hospital or inpatient unit licensed by the department of mental health and addiction services under section 5119. See Ohio Code 5122.01
- Mental illness: means a substantial disorder of thought, mood, perception, orientation, or memory that grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. See Ohio Code 5122.01
- Patient: means , subject to division (C)(2) of this section, a person who is admitted either voluntarily or involuntarily to a hospital or other place under section 2945. See Ohio Code 5122.01
- Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
- Person with a mental illness subject to court order: means a person with a mental illness who, because of the person's illness:
(1) 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;
(2) 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;
(3) 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;
(4) Would benefit from treatment for the person's 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;
(5)(a) Would benefit from treatment as manifested by evidence of behavior that indicates all of the following:
(i) The person is unlikely to survive safely in the community without supervision, based on a clinical determination. See Ohio Code 5122.01
- Probable cause: A reasonable ground for belief that the offender violated a specific law.
- Probate: Proving a will
- Prosecutor: means the prosecuting attorney, village solicitor, city director of law, or similar chief legal officer who prosecuted a criminal case in which a person was found not guilty by reason of insanity, who would have had the authority to prosecute a criminal case against a person if the person had not been found incompetent to stand trial, or who prosecuted a case in which a person was found guilty. See Ohio Code 5122.01
- Residence: means a person's physical presence in a county with intent to remain there, except that:
(1) If a person is receiving a mental health service at a facility that includes nighttime sleeping accommodations, residence means that county in which the person maintained the person's primary place of residence at the time the person entered the facility;
(2) If a person is committed pursuant to section 2945. See Ohio Code 5122.01
- Respondent: means the person whose detention, commitment, hospitalization, continued hospitalization or commitment, or discharge is being sought in any proceeding under this chapter. See Ohio Code 5122.01
- state: means the state of Ohio. See Ohio Code 1.59
- Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
AFFIDAVIT OF MENTAL ILLNESS
The State of Ohio
____________________ County, ss.
____________________ Court
________________________________________________________________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 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.
(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.
________________________________________________________________
(Name of the party filing the affidavit) further says that the facts supporting this belief are as follows: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
These facts being sufficient to indicate probable cause that the above said person is a person with a mental illness subject to court order.
The undersigned represents a trial court or a prosecutor who, as described in division (B)(1)(a)(v)(I) of section 2945.38 of the Revised Code, is alleging that the above said person is a person with a mental illness subject to court order: [ ] Yes [ ] No (please specify answer with an X). If Yes, please specify the name and address of the trial court or prosecutor:
________________________________________________________________________________________________________________________________
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 __________ __________ __________ Adult Next of Kin __________ __________
The following constitutes additional information that may be necessary for the purpose of determining residence:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dated this _____________ day of _______________, 20___
_____________________________
Signature of the party filing – the affidavit
Sworn to before me and signed in my presence on the day and year above dated.
____________________________
Signature of Probate Judge, – Deputy Clerk, or Notary – Public
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 _______________, 20___
_____________________________ – Signature of the party filing – the affidavit
The Legislative Service Commission presents the text of this section as a composite of the section as amended by multiple acts of the General Assembly. This presentation recognizes the principle stated in R.C. 1.52(B) that amendments are to be harmonized if reasonably capable of simultaneous operation.
Last updated March 17, 2023 at 1:23 PM