| Day/Date |
|
|
| Pt. Time In |
|
|
| Age |
|
|
| Race |
|
If other: |
| Sex: |
Male
Female |
|
| County of Residence |
|
| Presenting Issue
(SI, HI, Panic, DTs, OD, Etc.) |
|
| Brought in by: |
Other:
|
| Eval by: |
PET
ED Staff |
Name:
|
| Time PET* called |
|
| Time PET* arr. |
|
| Time PET*eval
over |
|
| Pt. Time out |
|
| Final
Disposition (TCSC, Inpt. psych., Inpt. Med.,
Home, Etc.) |
Other:
|
| If Inpatient:
Invol. or Vol.? |
Voluntary
In-Voluntary |
| All Dx
(psych., AOD, medical |
|
| Medical
complications: Please list |
|
| Funding source: |
|
| Required
seclusion or 1:1 – |
Yes
No |