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