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PROBATE COURT OF ________________ COUNTY, OHIO

_____________, JUDGE

IN THE INTEREST OF: ______________________________________________________

CASE NO. __________

CERTIFICATE OF PHYSICIAN

[R.C. 5119.92 and 5119.93(C)(1)]

Affiant states that he/she is a Physician as defined in Chapter 4731 of the Ohio Revised Code.

Affiant states that he/she examined the above named Respondent on: ______________________

and based on that examination, in his/her professional opinion, the Respondent:

☐does

☐ does not suffer from alcohol and/or drug abuse

☐does

☐ does not present an imminent danger or imminent threat of danger to self, family,

or others if not treated

☐ does

☐ does not present a substantial likelihood of such a threat in the near future; and

☐ can

☐ cannot

reasonably benefit from treatment

The facts that support Affiant’s belief that Respondent does suffer from alcohol and/or drug abuse

and the need for treatment:

______________________________________________________________________________

☐ Inpatient

☐ Outpatient

Type of Treatment:

Length of Treatment: ___________________________________________________________

FORM 26.1 – CERTIFICATE OF PHYSICIAN

Effective Date: July 1, 2016

Ohio Probate Form -

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