Hamilton County Law Enforcement Drop-off Form

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This field is for validation purposes and should be left unchanged.

Date:*

Time:*

: HH

MM

Complaint Number:

Officer Name:*

First Last

Badge #:*

Phone #:*

Email:

Law Enforcement Agency:*

Client Name:*

Address:*

Client Emergency Contact:

Emergency Contact Phone:

Please list any medication(s) or medical equipment brought with the client:

Which charge is being diverted?*

Please exclude individuals involved in felony charges such as domestic violence, DUI, or charges where there is a victim.

Specify:*

Description about crime &/or how LE got involved:

Location Client was picked up by LE:

Alcohol/substance abuse:*

Please list/describe:*

Describe client's current mental health and/or alcohol/substance abuse needs/issues:

Please provide any helpful info about the client such as history, medical conditions, abnormal behaviors, risk/danger/precautions, etc:

Name of VBHCS staff accepting Law Enforcement Drop Off:

Volunteer Behavioral Health Care Services