Hinds Behavioral Health Services Crisis Intervention Team law enforcement personnel and first responders must complete a CIT Contact Report each time a call occurs. Please complete the form below and submit it shortly after the crisis. CIT CONTACT REPORTAgency Your Agency NameCase Number Zone Primary Officer & Call Sign Date MM slash DD slash YYYY Arrival Hours : Minutes AM PM AM/PM Departure From Scene Hours : Minutes AM PM AM/PM Location CIT Officer Completing Report Call Call Dispatched Self-Initiated Referred By Other SUBJECTName First Last SSN Date of Birth Month Day Year Age Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Sex M F Race Caucasian African-American Native American Hispanic Other Veteran Yes No Don't Know PhoneEmergency Contact Emergency Contact PhoneRefer to EMS or Medical Assistance If:Individual Is Experiencing Overdose Vomiting Coughing Blood Convulsions/Seizures Slurred Speech Fluid or Blood From the Nose and/or Ears Drowsy/Cannot be Awakened Extreme Weakness When Was The Last Time The Individual Drank? Drank Don't Know When Was The Last Time The Individual Ate? Ate Don't Know Mental Health & Substance Abuse InvolvementEvidence of Drug/Alcohol Intoxication Yes No If Yes: Drugs Alcohol Don't Know If Known, List Substances Any Reported Mental Illness Yes No Medications Prescribed Yes No Don't Know Specify Medications, If Known Bring Any And All Medications And ContainersBehavior Observed(Check All That Apply)Behaviors Disorientation/Confusion Hallucinations Auditory Visual Unusually Scared or Frightened Disorganized Speech (Incoherent, Rambling) Depressed (Sadness, Crying, Flat Affect) Belligerent or Uncooperative Manic (Elevated Mood, Pressured Speech) Delusions Other Delusions, Specify, If Known Threats/Violence/Weapons Currently Displayedthreat Yes No Able To Care For Self Yes No Don't Know Suicidal Ideation/Talking About Suicide Yes No Don't Know Suicidal Attempt Yes No Don't Know Suicidal Note Yes No Don't Know Threats To Harm Self Yes No Don't Know Attempt To Injure Self Yes No Don't Know Presented Weapon Yes No Gun Knife Other Specify WeaponDid The Subject Threaten Or Engage In Violence Toward Another Person? Yes No Don't Know Prior ContactsPerson Known From Prior Police Contact Yes No Last Contact, If Known InjuriesInjuries During CIT Incident? Yes No #Officers #Consumer/Other DispositionDisposition 61 Consumer Stabilized/De-Escalated At Scene 62 Consumer Left On Scene, Referred To Outpatient 63 Transferred To Single Point-Of-Entry For Assessment 64 Arrested If Arrested, Misdemeanor If Arrested, Felony 65 Referred to ER/Medical Facility 66 Referred To Other Community Agency/Organization Additional Narrative, If NeededContact The Hinds Behavioral Health Services Mobile Crisis Unit Before Transporting, 601-955-6381.NameThis field is for validation purposes and should be left unchanged.
