SOP 220.03-att-8: Counselor Request Form (Attachment 8)

Division:
Unknown
Effective Date:
July 26, 2022
Reference Code:
IIC02-0004
Topic Area:
107 Policy-Counseling/Risk Reduction
PowerDMS:
View on PowerDMS
Length:
130 words

Summary

This form allows incarcerated individuals to request counseling services and assistance from their assigned counselor on various matters including appointments, parole information, account copies, notary services, program inquiries, housing changes, education/vocational information, reentry concerns, and grievances. The form requires the inmate to identify themselves, specify the type of service needed, and provide an explanation of their request. Staff must document their response and the form is retained in the offender's institutional file.

Key Topics

  • counselor request
  • inmate counseling
  • offender services
  • parole information
  • grievance process
  • transfer request
  • dorm change
  • reentry services
  • notary services
  • institutional counseling
  • inmate request form

Full Text

SOP 220.03
Attachment 8

07/26/22

# Counselor Request Form

Name: __________________________________________GDC#____________________________

Assigned Counselor: _______________________________Dorm____________________________

Instructions: If you need counseling services, please complete this form, and return it to your counselor
via mail or in a counseling session. Please check the space provided for the service you are requesting.

( ) Appointment with Assigned Counselor ( ) Parole Information

( ) Copy of Offender Account ( ) Special Visit

( ) Notary Services ( ) Transfer Request

( ) Program/Group Inquiry ( ) Detail Change

( ) Dorm/Bed Change ( ) Reentry Concerns

( ) Education/Vocation Inquiry ( ) Complaint (grievance)

( ) Request for Documents/ Forms

Explanation:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Signature: ______________________________ Date: _________________________________

For Staff Use ONLY

Date Received: ___________________________

Staff Response :
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Staff Signature ________________________________Date: __________________________________

Retention Schedule: Upon completion of this form, a copy shall be given to the offender. The original shall be
placed in the offender’s institutional file and maintained according to the official retention schedule for that file.

Attachments (17)

  1. Classification Committee Form (149 words)
  2. Classification Detail Request Form (41 words)
  3. Classification Appeal Form (Attachment 3) (94 words)
  4. Special Parole Review Recommendation Form (321 words)
  5. Classification Action Sheet - Reclassification Form (Inside Only) (71 words)
  6. Transitional Services Criteria (Work-Release) and Long Term Maintenance Criteria (670 words)
  7. Notification of Registered Sex Offenders Transfer (95 words)
  8. Counselor Request Form (Attachment 8) (130 words)
  9. Movement Plan Memo Template (319 words)
  10. Facility Stratification Plan Template (231 words)
  11. 48-Hour Waiver (Reclassification) (56 words)
  12. County Facility Placement Criteria (130 words)
  13. Offender Refusal Form (129 words)
  14. Operational Manual Template (202 words)
  15. Reclassification Move Request Form (122 words)
  16. Classification/Reclassification Summary Report (123 words)
  17. 48-Hour Classification Notification Form (75 words)
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