Appendix 5
Example - Emotionally Disturbed Person (E.D.P.) Form
Archived Content
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The following page contains an HTML version of the content currently found within the Dufferin-Peel Crisis form for Emotionally Disturbed People. This page is for information purposes only and is not a functional form.
Officer
Occurence number
Date (yy/mm/dd)
General
- Name of Subject
- Date of Birth (yy/mm/dd)
- Type of Dispatched Call
- Who Contacted Police
- Location
Check all boxes that apply
Appearance/Behaviour
General
- Co-operative with Police
- Rude
- Maintain Eye Contact
- Proper Clothing
Hygiene
- Dirty
- Clean
- Body Odour
- Malnourished
Activity
- Slow
- Agitated
- Restless / Fidgety
- Abnormal Movements
Thinking
Disorganized thinking
- None
- Mild
- Moderate
- Severe
- Describe Other
Abnormal speech
- Rapid
- Loud/Spearing
- Few Words
- Other
Odd beliefs
- Paranoid
- Grandiose
- Bizarre
- Other
Hallucinations
- Voices
- Visions
- Abnormal Sensations
- Other
Mood
- Sad
- Anxious
- Rapid Change of Mood
- Happy
- Flat
- Mood Not Appropriate for Situation
- Angry
Orientation
Ask and Record Responses
- Day
- Month
- Year
- Location
Dwelling
- Food in Fridge
- Clean
- Disorganized
- Rotten Food
- Dirty
- Fire Hazard
- Comment
Alcohol / Drug use
Alcohol
- Admitted
- Suspected
- Quantity
- Comment
Drug use
Admitted
- Drug Type
- Cocaine
- Marijuana
- Other
Suspected
- Drug Type
- Cocaine
- Marijuana
- Other
Danger issues
Active to self
- Suicidal Thoughts
- Self Mutilation
- Suicidal Act
Active to others
- Homicidal
- Aggressive
- Weapon(s) Present
Passive to self
- Poor Self Care
- Poor Judgment
- Clothing Inappropriate for Weather
Medical information
- Family Doctor
- Previous Apprehension MHA
- Hospital Associated With
- Psychiatrist
- Other Professional Agency
- Is Subject on Medication
- Yes
- No
- Name of Medication
- Pharmacy Name and Phone
Action
- Follow Up with Professional – Name
- Arrested/Charge
- Voluntary – Hospital Name
- MHA Section 17
- Form
Hospital information
Take to Hospital Known to Subject – if Unknown, Take Subject to Closest Hospital
Subject Does Not Choose the Hospital
- Hospital Name
- Admitted
- Arrested/Charge
- Doctor Seen
- Discharged
- Left Before Decision Was Made
- Total Time at the Hospital
Overall comments
- Date modified: