SOP_NUMBER: 208.06-att-14
TITLE: PREA Counseling Referral Form
DIVISION: Executive
TOPIC_AREA: 101 & 208 Policy-Compliance Unit
EFFECTIVE_DATE: 2022-06-23
WORD_COUNT: 141
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/936664
URL: https://gps.press/sop-data/208.06-att-14/

SUMMARY:
This form is used to document referrals for counseling services to inmates who have experienced sexual victimization or aggression, or who are involved in PREA allegations. The form tracks whether inmates accept or decline counseling services and documents their understanding of their right to voluntary participation without retaliation. It applies to all GDC facilities and must be retained permanently in the inmate's file.

KEY_TOPICS: PREA, sexual victimization, sexual assault, counseling referral, risk screening, PREA allegation, victim services, aggressor, inmate counseling, retaliation prevention, mental health services

ATTACHMENTS:
  1. Sexual Abuse_Sexual Harassment Prison Rape Elimination Act Education Acknowledgement Statement
     URL: https://gps.press/sop-data/208.06-att-1/
  2. PREA Sexual Victim_Sexual Aggressor Classification Screening Instrument
     URL: https://gps.press/sop-data/208.06-att-2/
  3. PREA Disposition Offender Notification Form
     URL: https://gps.press/sop-data/208.06-att-3/
  4. Sexual Allegation Response Checklist
     URL: https://gps.press/sop-data/208.06-att-4/
  5. Procedure for SANE Evaluation/Forensic Collection
     URL: https://gps.press/sop-data/208.06-att-5/
  6. PREA Investigative Summary
     URL: https://gps.press/sop-data/208.06-att-6/
  7. PREA Local Procedure Directive and Coordinated Response Plan
     URL: https://gps.press/sop-data/208.06-att-7/
  8. Retaliation Monitoring Checklist
     URL: https://gps.press/sop-data/208.06-att-8/
  9. Sexual Abuse Incident Review Checklist
     URL: https://gps.press/sop-data/208.06-att-9/
  10. PREA Initial Notification Form
     URL: https://gps.press/sop-data/208.06-att-10/
  11. PREA Staffing Plan Template
     URL: https://gps.press/sop-data/208.06-att-11/
  12. PREA Victim Advocate Request Form
     URL: https://gps.press/sop-data/208.06-att-12/
  13. Contractor/Volunteer Verification Form – Sexual Abuse/Sexual Harassment (PREA)
     URL: https://gps.press/sop-data/208.06-att-13/
  14. PREA Counseling Referral Form
     URL: https://gps.press/sop-data/208.06-att-14/
  15. Investigative File Summary Checklist
     URL: https://gps.press/sop-data/208.06-att-15/
  16. Investigative File Detail Checklist
     URL: https://gps.press/sop-data/208.06-att-16/
  17. Prison Rape Elimination Act (PREA) Offender Brochure (English)
     URL: https://gps.press/sop-data/208.06-att-17/
  18. PREA Offender Brochure (Spanish)
     URL: https://gps.press/sop-data/208.06-att-18/
  19. Staff Guide on the Prevention and Reporting of Sexual Misconduct with Offenders
     URL: https://gps.press/sop-data/208.06-att-19/

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FULL TEXT:
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SOP 208.06
Attachment 14

06/23/22

# **GEORGIA DEPARTMENT OF CORRECTIONS** **PREA Counseling Referral Form**


Reason for referral:


`☐` **Risk Screening**


The agency shall offer counseling to any offender with prior history of sexual victimization or
aggressiveness within 14 days of risk screening.

Date of Screening: ________________ Date of Counseling Referral: ________________


`☐` **PREA Allegation**


The agency must offer counseling services to named victims and aggressors in any PREA
allegation.


**Select one:**


**I** _**DO**_ **accept the offer of counseling services.**


**I** _**DO NOT**_ **accept the offer of counseling services.**


This is to acknowledge I understand I have the right to counseling services. I further understand
this is a voluntary service and I cannot be retaliated against for refusal to participate.


______________________________       _____________________


Offender Name GDC #


______________________________ _____________________


Signature Date


Record Retention: Retain permanently in the offender’s institutional file. If the referral is from a PREA allegation a
copy is placed in the investigative file.