SYP Hospital Form

Forename *

Surname *

Date of Birth dd/mm/yyyy *

Home telephone number

Mobile telephone number

Language *

Is English their first language?

If no, please describe language spoken and whether English can be understood.

Date of Admission: (if applicable)*

Ward: (if applicable)*

Legal Status:*

Are there issues that effect this persons mental capacity: (please describe)*

Risk of harm to self/others:*

Current Description:*

Personal Information – Please complete as fully as possible. Where “yes” please describe. Where not relevant please mark “n/a”.

Has the patient previously been missing from the hospital?*

Is the reported behaviour out of character?*

Is the person vulnerable?*

Is this person known to have self-harmed or attempted suicide?*

Is the person thought to be a victim of crime? (including domestic violence, harassment or hate crime)*

Is the person thought to be a victim of sexual exploitation?*

Under 18’s only – Is the person on the Child Protection Register?*

Under 18’s only – Is the person a looked after child? If so, which LA?*

Is the patient, or is the patient thought to be, a drug user or alcohol abuser?*

When last seen, what was the person doing, what was the person expected to do next?*

Please confirm that the following checks have been completed.

Whereabouts *

Check CCTV for the patient, identifying last known whereabouts

Buildings and Grounds *

Search the buildings and ground

Security Aware *

Ensure security staff are aware

Next of Kin *

Contact next of kin – to advise of the patient’s status and to establish if they know of patient’s whereabouts

The following questions may not be able to be answered. Where details are known, please complete as fully as possible. Where unknown/inapplicable, please mark, “n/a”.

Does the person have issues with school; college; employment or finances?*

Does the patient use social network sites? If so, please describe.*

Do they have access to transport?*

Does the patient have access to money?*

Any indications that preparations have been made to leave? (bags being packed, phone calls made, passport located etc.)*

Details of visitors*

Any known previous addresses; places of interest; clubs/hobbies; place of employment etc.*

Any other relevant information to assist in understanding the risks and locating the individual.

Continue to risk assess and monitor the situation. If new information becomes available or the threat level changes please re-contact South Yorkshire Police.

Staff Completing: (Name/Role) *

Hospital: *

Contact Details: (Ward/Department and telephone numbers) *

Email Address *

Confirm Email Address *

Disclaimer

There is no requirement to disclose this form in its completed or incomplete state unless there is a justifiable policing requirement.

It is the responsibility of the person reporting or the duty manager to ensure that this document is up to date and completed fully to the best of their knowledge. As such, that person will be responsible for all information provided on first instance. That person shall then fully update anyone else who shall temporarily assume the responsibilities of primary contact (during periods of leave/rest etc.)

CONCERN FOR WELFARE REFERRAL - NHS USE ONLY