Jail Triage Quick Reply Form
Please fill out this form and press submit.
Episode #:
Name of Inmate:
SS#:
DOB:
Name of CMHC:
Name of Jail Facility:
Name of Clinician providing Service:
Clinician's Credentials:
Date of Service:
Service Start Time:
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12
:
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59
AM
PM
Length of Service:
0
1
2
3
4
5
6
7
8
9
:
00
15
30
45
Type of service(s) provided(check all that apply):
Evaluation
Crisis Counseling
Jail Consultation
Recommendation (check one):
Increase risk management protocol
Maintain risk management protocol
Decrease risk management protocol
Referral made for (check all that apply):
Psychiatric Services
Hospitalization
202.a Civil Commitment
504 Competency
Voluntary
Additional MH/MR treatment
ABI Services
Medical Services
Comments: