Date/Time Assigned
MENTAL HEALTH - CRISIS INTERVENTION (CIT) REPORT CHICAGO POLICE DEPARTMENT
Previous Interaction
Supervisor
On-View
IR No. (If applicable)
CB No. (If applicable)
Was Mental Health component indicated before arrival? No Yes
If known, list no. of times
No
Subject Information Name Sex Male
Assigned by OEMC
Beat of Occurrence
RD No. (If applicable)
Event No.
Yes
/ Location Code
Address of Incident
Address Age
Date of Birth
Race
Female
Living Arrangements
1-Black
4-White-Hispanic
Homeless Hospitalization/Treatment Prior mental health hospitalization Prior mental health treatment Current mental health treatment If known, list Doctor's Name and Agency
Family Yes Yes Yes
2-White
5-Amer. Ind/Alask.
Independent No No No
Currently taking medication for mental illness Yes No (If known, indicate name and last time the medication(s) were taken)
3-Black-Hispanic
7-Other
6-Asian/Pacific Islander
Assisted Living
Unknown
Unknown Unknown Unknown Unknown
Did you observe any of the following (Check as many as apply): Nothing unusual observed Absurd, illogical thinking/talking Abnormal behavior/appearance Hearing voices/hallucinating Anxious/excited Paranoid or suspiciousness Violent behavior
Severe, depressed mood Suicidal talk Suicidal gesture(s) Signs of alcohol/illegal drug use Possible developmental disability Aggressive/threatening behavior or speech Weapons, if checked Displayed
Used
Member Actions Methods Used (Check all that apply) Verbal Physical restraint Type of facility Hospital Substance Abuse Facility OC Chemical Weapon Community Mental Health Facility Homeless Shelter Canine Governmental Agency Home Other Impact Weapon Specify Hospitalization Taser No Yes If yes, Voluntary Involuntary Firearm Yes Petition completed by member No Other Reason for Hospitalization Specify Harm to others Harm to self Basic needs not met
Contact only: Card No. Transported to
CIT Officers (This section to be completed by CIT Officers only) 4-Violence 2- Anger Rate highest level of subject 1- Anxiety 3-Hostility Subject's actions Assailant Cooperative Active Resister Passive Resister No Yes Yes Were the techniques successful? Were CIT Training Techniques Used? No Star No. Member's Name Star No. Beat No. Beat No. Member's Name CIT CIT CIT Supervisor's Approval
Date/Time Completed
Reports Attached Arrest Report
Case Report TRR Other
/ CPD-15.520 (Rev. 2/13) Please return this report to the CIT Program, Unit 441. Fax # (312) 745 - 6980. Use reverse side for any additional information and attach all relevant reports.