SOP_NUMBER: 220.03-att-8
TITLE: Counselor Request Form (Attachment 8)
REFERENCE_CODE: IIC02-0004
DIVISION: Unknown
TOPIC_AREA: 107 Policy-Counseling/Risk Reduction
EFFECTIVE_DATE: 2022-07-26
WORD_COUNT: 130
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105814
URL: https://gps.press/sop-data/220.03-att-8/

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

ATTACHMENTS:
  1. Classification Committee Form
     URL: https://gps.press/sop-data/220.03-att-1/
  2. Classification Detail Request Form
     URL: https://gps.press/sop-data/220.03-att-2/
  3. Classification Appeal Form (Attachment 3)
     URL: https://gps.press/sop-data/220.03-att-3/
  4. Special Parole Review Recommendation Form
     URL: https://gps.press/sop-data/220.03-att-4/
  5. Classification Action Sheet - Reclassification Form (Inside Only)
     URL: https://gps.press/sop-data/220.03-att-5/
  6. Transitional Services Criteria (Work-Release) and Long Term Maintenance Criteria
     URL: https://gps.press/sop-data/220.03-att-6/
  7. Notification of Registered Sex Offenders Transfer
     URL: https://gps.press/sop-data/220.03-att-7/
  8. Counselor Request Form (Attachment 8)
     URL: https://gps.press/sop-data/220.03-att-8/
  9. Movement Plan Memo Template
     URL: https://gps.press/sop-data/220.03-att-9/
  10. Facility Stratification Plan Template
     URL: https://gps.press/sop-data/220.03-att-10/
  11. 48-Hour Waiver (Reclassification)
     URL: https://gps.press/sop-data/220.03-att-11/
  12. County Facility Placement Criteria
     URL: https://gps.press/sop-data/220.03-att-12/
  13. Offender Refusal Form
     URL: https://gps.press/sop-data/220.03-att-13/
  14. Operational Manual Template
     URL: https://gps.press/sop-data/220.03-att-14/
  15. Reclassification Move Request Form
     URL: https://gps.press/sop-data/220.03-att-15/
  16. Classification/Reclassification Summary Report
     URL: https://gps.press/sop-data/220.03-att-16/
  17. 48-Hour Classification Notification Form
     URL: https://gps.press/sop-data/220.03-att-17/

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FULL TEXT:
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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.