LAW ENFORCEMENT CONTACT REPORT

PART 1
GROUP HOMETRANSITIONAL HOUSING PLACEMENT PROVIDERYOUTH HOMELESS PREVENTION CENTERSTRANSITIONAL SHELTER CARE FACILITYTEMPORARY SHELTER CARE FACILITY
Client's Length of Stay at the time of the Incident
Client's Primary Therapist

First NameLast Name
LICENSED CAPACITY
CURRENT CENSUS
6 BEDS
FACILITY
AGGRESSIVE ACT - CLIENT TO CLIENTAGGRESSIVE ACT - CLIENT TO STAFFAGGRESSIVE ACT - STAFF TO CLIENTAGGRESSIVE ACT - OTHER TO CLIENTAGGRESSIVE ACT - CLIENT TO OTHERBEHAVIOR EPISODEAGGRESSIVE ACT - UNKNOWNSUBSTANCE ABUSEUNAUTHORIZEDABSENCE (AWOL)HARM TO SELFCSE RELATEDPSYCHOLOGICALPROPERTY DAMAGENON-PHYSICAL AGGRESSIONTHEFTALLEGED SEXUAL ABUSE - SEXUALALLEGED SEXUAL ABUSE - PHYSICALALLEGED SEXUAL ABUSE - PSYCHOLOGICALFINANCIALNEGLECTOther

IF MULTIPLE CHILDREN INVOLVED, FOLLOW DESIGNATION "C1" FOR CHILD 1 AND SO ON

AGENCIES/INDIVIDUALS NOTIFIED: C1

AGENCIES/INDIVIDUALS NOTIFIED: C2

AGENCIES/INDIVIDUALS NOTIFIED: C3

AGENCIES/INDIVIDUALS NOTIFIED: C4

YESNO
IF YES, EXPLAIN THE TECHNIQUES USED. IF NO, EXPLAIN WHY NOT.
YESNO
YESNO
IF NO, EXPLAIN WHY NOT.
FACILITYSCHOOLOTHER
IF OTHER, EXPLAIN WHERE
DESCRIPTION OF INCIDENT. INCLUDE NATURE OF INCIDENT, ACTION TAKEN BY STAFF IN RESPONSE TO THE INCIDENT, AND DISPOSITION OR CURRENT STATUS OF THE INCIDENT. FOR INCIDENTS IN GROUP HOMES, INCLUDE A DESCRIPTION OF THE EVENTS LEADING UP TO THE INCIDENT.
YESNO
IF YES, LIST NAME OF ATTENDING PHYSICIAN, FINDINGS, AND TREATMENT, IF ANY.
YESNO
PREPARRED BY

NAMETITLE
DATE PREPARED

MonthDayYear
Date
REVIEWED/APPROVED BY

NAMETITLE
DATE APPROVED

MonthDayYear
Date
PART 2
FACILITY
DATE OF INCIDENT

MonthDayYear
Date
DATE OF FOLLOW UP

MonthDayYear
Date
YESNO

LIST ANY CHILD INVOLVED (WHETHER OR NOT ALLEGED TO HAVE COMMITTED A CRIME), INCLUDE CHILD(REN) FROM ORIGINAL INCIDENT (PART 1):

LIST ANY STAFF INVOLVED

STAFFOTHER YOUTHNEIGHBOROTHERUNKNOWN
5150COUNSELLED BY LAW ENFORCEMENTMENTAL HEALTH EVALUATIONUNKNOWNARREST(S) MADEJUVENILE HALLSTAFF DISCIPLINARY ACTIONDETAINED BY LAW ENFORCEMENTINTERVIEWED BY LAW ENFORCEMENTRETURNED TO FACILITYPLACEMENT TERMINATEDLAW ENFORCEMENT DID NOT RESPONDOther
(If any boxes above are checked, explain briefly here and include any additional information. Attachadditional sheets as needed.)
PREPARED BY

NAMETITLE
DATE PREPARED

MonthDayYear
Date
REVIEWED BY

NAMETITLE
DATE REVIEWED

MonthDayYear
Date
Signature

Clear
Should be Empty:

PART 1