Mental Health Transport Booking Form

Name of patient

Date of birth

NHS number

Gender of patient Male Female

Is the service user aware that they are being transported? Yes No

Is consent obtained? Yes No

Is a secure area in the vehicle required for the transport? Yes No

If yes, please specify why the secure area is required

What section is the service user?

If other, please specify

Current risk Absconsion risk Physical aggression Verbal aggression Sexually inappropriate behaviour Self harm Gender issues (staffing preference) Racial issues (staffing preference)

Please explain the service user’s presentation over the last 24 hours, including risk history

Level of risk

Do you require the use of mechanical restraint (handcuffs)? Yes No

Are there any illnesses, injuries or disabilities that we should be aware of? Yes No Unknown

If yes to the above, how is this managed?

Does the patient have any sensory impairment? None Sight Hearing Intoxication Other

If other, please specify the sensory impairment

Are there any safeguarding issues for this patient at the moment? Yes No

If yes, please specify the safeguarding issue

Are there any known allergies or special dietary requirements? Yes No Unknown

If yes, please specify the allergies or dietary requirements

Will the service user be medicated prior to conveyance? Yes No

PSS Secure Transport

Mental Health Transport — Booking

Pick up information

Destination information