Patient's name: _____________________________________________________________________
Place of incident (e.g. home, building, roadside):____________________________________________
Person requesting police attendance (e.g. relative, bystander, shopkeeper): ______________________
Contact details of witnesses/relatives: _____________________________________________________
Reason given by patient for incident: ______________________________________________________
Description of incident/Reason why police requested/Reason for Section 23:
Additional comment's on patient's appearance, speech, behaviour or emotional
state? (e.g. dishevelled,
dirty, agitated/passive, combative, uncooperative/cooperative, disorientated, intoxicated, incoherent,
incomprehensible, rapid speech, paranoid, tearful, inconsolable):
Circle any of the following and give details (you can choose more than one)
History of violence?
History of property damage/violence?
Possession of weapons?
History of drug/alcohol use?
History of psychiatric illness?