Mental Health Incident Report

Date & Time of Incident: *

Date

Time

Location: *

If Other - Please Specify *

Person Completing Report *

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Last

Position *

Mobile *

Person Involved *

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Last

Age *

Parent/Guardian (if under 18)

First

Last

Emergency Contact *

First

Last

TYPE OF INCIDENT *

Tick All That Apply

If Other - Please Specify

DESCRIPTION OF INCIDENT *

Describe exactly what happened. Include: What you observed What was said Who was present Sequence of events

EXACT WORDS USED

If the individual disclosed information, record their words as accurately as possible.

OBSERVATIONS *

Appearance

Behaviour observed

IMMEDIATE RISK ASSESSMENT

Was anyone in immediate danger?

If yes, explain:

Was emergency assistance required? *

Details:

ACTIONS TAKEN *

Tick all that apply.

Please provide details:

PEOPLE INFORMED

Name | Relationship | Time

FOLLOW-UP REQUIRED

Please provide details:

ADDITIONAL NOTES

CONFIDENTIALITY

This report contains confidential personal information and should be stored securely in accordance with UK GDPR and your safeguarding procedures.

Access should be restricted to authorised personnel only.

COMPLETED provide Please

REPORT COMPLETED BY *

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Last

REVIEWED BY *

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Last

Good Practice Guidance for Staff

When completing this form:

Record facts, not opinions.
Use the individual's exact words wherever possible.
Do not diagnose or speculate.
Record events as soon as practical after the incident.
If there is an immediate risk of serious harm, contact emergency services without delay.
For children and young people, follow your safeguarding procedures and escalate concerns to your Designated Safeguarding Lead as appropriate.