Crisis Intervention Team (CIT) Report                                                                                                               
                                                                                                        
Date:        Arrival Time:        End Time:      Consumer name:  Last, First, Middle – Nickname:       District / Zone:           

Location of incident:   

                                                                                              

Consumer Address and Phone Number

                                                                                              

Age:         Gender:          Race / Ethnicity:          English speaking:    DOB:                   Height:               Weight:  
                  (  ) M   (  ) F                                            (  ) Yes   (  ) No 

S

Name of Consumer’s Family / Legal Guardian: ___________________________________________

Phone number of Family: _________________________ 

Reason for call:                                  Was force used? Yes (  ) No (  ) If yes, explain in narrative section of this form.                                                     

 ____ 911 call                                           Consumer Injuries:                                       Officer(s) Injuries:   
 ____ Involuntary Pick up                       (  )   None                                                          (  )  None
 ____ Wellness check - follow up          (  )   Prior to law enforcement arrival             (  )  Slight                                                                 
 ____ Other                                              (  )   During law enforcement encounter        (  ) Severe

In your opinion, should a CIT officer been dispatched for this call?  (  ) Yes   (  )  No  If no, explain in narrative 

Consumer’s Status: [Check all that apply]                Medication compliance:  [Check all that apply]

(  ) Current mental health consumer.                 Consumer is prescribed psychiatric meds?  (  ) Yes (  ) No (  ) Unknown 
(  )  New mental health consumer.                      If yes, is consumer compliant with meds?    (  ) Yes (  ) No (  ) Unknown                 
(  )  Consumer is on probation.                     
(  )  Consumer is homeless.                                             Substance Abuse:  [Check all that apply]  
(  )  Consumer has outstanding warrant             Drug use suspected?         (  )  Yes  (  )  No  
(  )  Unknown or other                                        Alcohol use suspected?    (  )  Yes  (  )  No

Disposition of the CIT call:        Enter as CAD Call Disposition 

1 -   (  )  Consumer unable to be located.
2 -   (  )  Complaint unfounded.  
3 -   (  )  Situation resolved on scene, consumer not taken into custody or transported.   
4 -   (  )  Consumer transported to crisis unit - voluntary.  
5 -   (  )  Consumer transported to crisis unit – with involuntary commitment petition.
6 -   (  )  Consumer transported to crisis unit – on emergency commitment basis.
7 -   (  )  Consumer transported to medical hospital – Hospital Name: _________________________________________________     
8 -   (  )  Consumer transported to psychiatric hospital – with involuntary commitment petition.
9 .   (  )  Consumer transported to psychiatric hospital – on emergency commitment basis.
10 - (  )  Consumer transported to other location (home, shelter, bus depot, etc.)  [explain in narrative section]  
11 - (  )  Consumer arrested and transported to jail.  List the charges:  ________________________________________________

Prior to CIT: Could you have taken this consumer to jail? (  ) Yes   (  ) No
If yes, what would have been the charges?_____________________________________________________________ 

Officer Observations:  [Check all that apply and complete narrative on back of form]

(  ) Violent – assaulted someone                (  ) Appears very anxious or fearful              (  ) Visual hallucinations
(  ) Physically threatened others                 (  ) Sad expression or crying                         (  ) Talks to self / auditory hallucinations                (  ) Verbally threatening to others               (  ) Speaks very rapidly or uncontrollably    (  ) Appears to have delusions
(  ) Hostile, belligerent or argumentative   (  ) Incoherent or illogical speech                  (  ) Seems confused or disoriented          
(  ) Attempted to kill or harm self                (  ) Restless / hyperactive / agitated              (  ) Unsteady gait / difficulty walking
(  ) Threatened to hurt or kill self                (  ) Sexually inappropriate behavior              (  ) Inappropriate attire for the weather 
(  ) Doesn’t answer questions or mute       (  ) Expresses inflated self importance         (  ) Poor personal hygiene
(  ) Overly suspicious / paranoid                 (  ) Mental retardation suspected                  (  ) Presence of urine or feces
                                                                                                                                                  (  ) Other (Explain in Narrative)      

form #: CIT 061706                

Police Department Name:		

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Note: This form is only for CIT officer’s use

CIT Officer’s Name:		Badge #		Date Completed:		

CIT Supervisor:		 Date reviewed: