PROBATE COURT OF ________________ COUNTY, OHIO
_____________, JUDGE
IN THE INTEREST OF: ______________________________________________________
CASE NO. __________
NOTICE TO RESPONDENT AND EMERGENCY ORDER
TO REPORT TO HOSPITAL
[R.C. 5119.95]
To: _______________________
_______________________
_______________________
You are hereby notified that on __________________, _______________ filed in this
Court a Petition alleging that _________________ is a person in need of involuntary treatment
for alcohol and/or other drug abuse by Court Order.
The Court has received a certification from a qualified health professional that
_________________________________ suffers from alcohol and other drug abuse and
presents an imminent danger or imminent threat of danger to self, family, or others as a result
of alcohol and other drug abuse.
By clear and convincing evidence, the Court finds that __________________ presents
an imminent danger or threat of danger to self, family, or others as a result of alcohol and other
drug abuse and hereby orders that __________________ be hospitalized immediately at the
following hospital:
Place:____________________________________________________________________,
____________________ is to be held at the hospital until:
□ Date:_____________________________, Time:_______________________, or
□ The time of the Hearing.
The Petition is set for a Hearing before this Court at:
Place:__________________ County Probate Court,________________________________,
Date: _______________________ Time:_______________________________
FORM 26.6 – NOTICE TO RESPONDENT AND EMERGENCY ORDER TO REPORT TO HOSPITAL
Effective Date: July 1, 2016
