HIPAA Notice- Always remember to keep all Protected Health Information (PHI) secured at all times Unique ID#: Crisis Intervention Team (CIT) Report Reporting Officer:
Officer Code #:
Date:
Officer Arrival Time:
Consumer Name: Last:
Work location:
Officer Departure Time: First:
Middle:
Nickname:
Location of Incident:
Consumer address:
Address:
Address:
City:
State:
Total time spent:
Zip Code:
City:
State:
Zip Code:
Preferred phone #: : D.O.B.:
Age:
Gender:
Language:
Race:
Ethnicity:
Military Service:
Emergency Contact:
Contact Phone #:
Reason for Call:
Did 911 dispatcher request CIT Officer:
Threat assessment:
Nature of threat/weapons present:
Consumer Injuries (Prior Officer arrival): Officer Injuries:
Who else responded?
Was force used: Officer Observations:
Consumer Injuries (After Officer arrival):
If force used, level? : Signs:
Symptoms:
Do you suspect the presence of: A mental illness:
IDD:
Has the person been reported as having a mental illness: Is the consumer currently taking medications: Is consumer currently: In treatment:
On probation:
Outstanding warrants:
Consumer went to:
Transported by:
Was the consumer charged with a crime: Narrative:
04/15/2015
If Yes, what illness?
On outpatient commitment:
Was consumer placed under IVC: Transport:
Alcohol use:
If yes, are they taking them as prescribed?
Does the consumer have: Recent known Trauma: Was there a diversion effort:
Drug use:
IVC initiated by: Officer time spent at facility: Prior to CIT would you have taken consumer to jail:
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