Appendix 5
Example - Emotionally Disturbed Person (E.D.P.) Form

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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