Shelton PD LINKED - Autism Safety Form

This form provides communications and quick access to important information regarding your individual with Autism or within the special needs community.

Please be sure to include any and all information that you believe can support Shelton Police Department in ensuring the safety of an individual with Autism or special needs in a crisis situation.
First Name
Last Name
Any nickname individual may answer to
Address
Sex

MaleFemale
DOB
Weight
Height
Hair color
Eye color
Mother’s Name/Cell #
Father's Name/Cell #
Emergency Contact #1 Name/Cell #
Emergency Contact #2 Name/Cell #
Will individual respond to his/her name?
Does the individual have a fear of K9s?
Individual’s official diagnosis
Individual’s identifying marks, medications (and dosage) & medical needs
Individual’s identifying marks, medications (and dosage) & medical needs
Please check those that apply:

BlindDeafNon-VerbalIntellectual DisabilitiesCognitive ImpairmentProne to Seizures
If other, please explain
Communication Ability (Check all that Apply)

VerbalNon-VerbalASLAAC DevicePEC CardsHas Written AbilityScriptsCan Respond to Yes or NO Questions
List Below best means of communication in stressful situation:
Sensitivity To:

NoiseTouchLightCrowdsTextures
Behaviors:

Sensory SeekingVocal StimsSelf-InjuriousLack of fear of dangerElopementAggressionEye Contact AvoidanceWill run if chased
Does this individual have the ability to follow commands?
Dislikes of Individual
Favorite attractions or locations:
Favorite toys, objects, songs, movies, TV shows, discussion of topics:
Additional Information first responders may need:
I, blanks , give my full permission to the Shelton Police Department to retain this information, to be kept on file for the purposes of identification and the assistance relative to Autistic and Special Needs Individual Identification efforts and related activities.
File Upload - Please Upload a recent photo, one taken within the last year

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