Restraint Consent and Monitoring Form

Captures informed consent, justification, monitoring, least-restrictive review, and release documentation for physical restraint use.

Event Details

• Date of Event
• Time Restraint Began
• Person Identifier
  Use the facility identifier or record number. Do not enter unnecessary PII.
• Location
• Type of Restraint
• Immediate Risk or Safety Concern
  Briefly describe the behavior or condition that created the need for restraint.

Consent and Authorization

• Was the person able to provide informed consent at the time?
• Consent or Authorization Obtained
• Consent Method
• Consent Disclosure and Explanation Provided
  Confirm that the risks, purpose, and expected duration were explained using the least restrictive approach available.
• Reason Consent Was Not Obtained

Least Restrictive Review

• Alternatives Attempted Before Restraint
• Why Was This the Least Restrictive Effective Option?
• Supervisor Notified

Monitoring Record

• Monitoring Interval (Minutes)
• Monitoring Log

Release and Review

• Date of Release
• Time of Release
• Release Criteria Met
  Confirm the person was released when safe and clinically appropriate.
• Post-Event Review / Debrief
• Follow-Up Actions

Submitter and Audit Trail

• Submitted By
• Role / Title
• Signature