SOP 508.14-att-1: Mental Health Reception Screen Form (M30-01-01)

SOP 508.14
Attachment 1

9/13/19

Georgia Department of Corrections Name: _________________ GDC #: _______________

Mental Health Reception Screen Form DOB: ____________ Race: ________ Sex: __________

Facility:_____________________ Date:_________________

|Questions|Yes|No|If yes, please explain|
|---|---|---|---|
|1. Are you currently prescribed psychotropic
medications or have been prescribed within last 6
months medications for a mental illness?|||If yes, name of medication(s):|
|2. Do you have a history of self-injury or a suicide
attempt?|||If so, when?|
|3. Have you had a serious suicide attempt/plan in the
past year?||||
|4. Do you have present thoughts or plans of self-injury
or suicide?||||
|5. Do you have a mental health inpatient history?
[do not include substance abuse treatment—see #14]|||If so, when?
[Refer for MH evaluation if inpatient treatment occurred<5 years ago]|
|6. Do you have a mental health outpatient history?
[do not include substance abuse treatment—see #14]|||If so, when?
[Refer for MH evaluation if outpatient treatment occurred <5 years ago]|
|7. Did you have mental health treatment in jail/prison?
||||
|8. Do you have a history of being a victim of abuse?
(physical / psychological / sexual)|||If yes, is mental health treatment desired?
Circle: yes no|
|9. Do you identify as transgender or intersex?
|||If yes/no, are there observable physical characteristics
of the opposite gender? Circle: yes no|
|10. Have you ever hurt another person sexually?
Have you ever been charged with a sex offense?|||If yes, is treatment desired?
Circle: yes no
(If yes, person completing this form must contact DW of Care &
Treatment for a Risk Reduction Services referral)|
|11. Do you have a history or current thoughts of
assaultive/violent behavior?||||
|12. Do you have a history of head trauma?
||||
|13. Do you have a history of special education/disability
benefits?||||
|14. Do you have a history of substance abuse treatment?|||If so, when? Type: [ ] Inpatient [ ] Outpatient|

FOR INTRA-SYSTEM TRANSFERS to non-mental health facilities. This is only a screen, not meant for referrals unless,
offender answers yes to questions 1 – 8. If so, contact the catchment area facility to schedule a follow-up with a Mental Health
Provider within 14 calendar days. For questions 9-14 contact the catchment area facility for guidance.

Are there risk factors associated with the offender’s situation that suggest the need for further evaluation/monitoring (e.g., high profile
case with offense that puts offender at risk with peers; lengthy sentence, particularly if first incarceration)? [ ] Yes [ ] No
_______________________________________________________________________________________________________

Clinical Impressions and behavioral observations: _______________________________________________________________

________________________________________________________________________________________________________

[ ] Further Mental Health Evaluation (may need services) [ ] No Further Mental Health Evaluation
___________________________________ ______________________________________
Signature (staff member completing this form)/Title Print Name

___________________________________ ______________________________________
Reviewer’s Signature (Catchment area Clinical Director/Consultant)/Title Print Name

Form no. M30-01-01 Page 1 of 1

Retention Schedule: Upon completion, this form shall be placed in the offender’s medical file (original - section 5) and mental health
file (copy-section 4). At the end of the offender’s need for mental health services and/or sentence, the mental health file shall be
placed within the offender’s health record and retained for 10 years.