Emergency Department No No Police Station N/A N/A Other Was local Mental Health Place of Safety Y/N available? If No, why? Where did the person go? Section B Initial Screening – Is the client under the influence of Drugs Yes and/or alcohol? No N/A Both Known medication / Medical conditions Physical Injury and any treatment required? Was the patient restrained? Yes No Restraint used (Taser/Handcuffs/Leg strap restraints/Physical restraint/CS Spray/PAVA Spray) Details of restraint including length of time Assessment delayed? Yes No By how long and reason? Other comments Joint Risk Assessment Police PNC / CIS checks done? Yes No N/A Agreed perception of risk Yes No N/A State who (NHS, Police, Other, Please specify) Name Profession/Role Reason Agreed as to whether the police remain? Length of police presence? Was there a disagreement about police Yes support? No Was this escalated? If so, to who
Emergency Department Police Station Other No N/A No N/A Was local Mental Health Place of Safety available? Y/N If No, why? Where did the person go? Section B – Initial Screening Is the client under the influence of Drugs and/or alcohol? Yes No N/A Both Known medication / Medical conditions Physical Injury and any treatment required? Was the patient restrained? Yes No Restraint used (Taser/Handcuffs/Leg strap restraints/Physical restraint/CS Spray/PAVA Spray) Details of restraint including length of time Assessment delayed? Yes No By how long and reason? Other comments Joint Risk Assessment Police PNC / CIS checks done? Yes No N/A Agreed perception of risk Yes No N/A State who (NHS, Police, Other, Please specify) Name Profession/Role Reason Agreed as to whether the police remain? Length of police presence? Was there a disagreement about police support? Yes No Was this escalated? If so, to who
MHA-PGN-06-App4-Section135-136Form-V01-Iss-2-Oct-17.docx