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)

Forensic/Criminal history?

History of violence?

History of property damage/violence?

Possession of weapons?

History of drug/alcohol use?

History of psychiatric illness?