City of Peabody

Peabody Police Autism Form

"*" indicates required fields

Individual's Information

MM slash DD slash YYYY

Physical Description

Gender*
Max. file size: 10 MB.

Medical Information

Diagnosis and Medical Conditions
Will emergency lights trigger behavior?
Will siren trigger behavior?

Safe Person

Safe Person's Name
Safe Person's Address

Behavior Traits

Verbal?
On police arrival will there be fight or flight?
Responds to Name?
Eye Contact?
Delayed Speech?
Impaired Sense of Danger?
Responds to Verbal Commands?
Repetative Behavior?