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Family Safety Questionnaire

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Steps

  1. 1. Person Completing this Form(current)
  2. 2. Physical Description
  3. 3. Residential Information
  4. 4. Parent/Guardian Information
  5. 5. Diagnosis
  6. 6. Wandering & Sensory Issues
  7. 7. Helpful Information for Safety Personnel
  8. 8. Emergency Contact Information
  9. 9. Other Contact Information
  10. 10. Vehicle Information
  11. 11. Photo (Optional)
  12. 12. Release of Information

  • Person Completing this Form

    2. This form allows families and guardians of individuals with dementia, autism spectrum disorder or other cognitive disorders to provide information to our safety services (fire and police) to be used only in the event of an emergency situation.

      Our safety services will use the information you provide for the sole purpose of identifying and protecting this individual in an emergency or crisis situation. Click here to learn more.

      We look forward to partnering with you on this effort. Thank you.
    11. Mental Health Contact*

      I would like contact with the mental health team in the city.