Restraint form fill in online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Program/Facility License Number and Name at the top of the form. This identifies the location where the restraint occurred.
3. Fill in the Report Date, AHCCCS Provider ID, Address, and Phone number for accurate record-keeping.
4. Complete the Contact Person/Title section with relevant details of the individual responsible for reporting.
5. In the Reporting Information section, provide details about the recipient including their name, SS#, age, gender, diagnoses, and medications.
6. Document any seclusion or mechanical restraints applied by filling out their respective sections with dates, times, durations, and names/titles of staff involved.
7. Indicate if any physical injuries occurred during restraint and provide necessary details regarding medical intervention needed.
8. Conclude by detailing de-escalation methods attempted prior to restraint and summarizing outcomes from debriefing sessions.

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