SOP_NUMBER: 508.14-att-1
TITLE: Mental Health Reception Screen Form (M30-01-01)
DIVISION: Mental Health
TOPIC_AREA: 508 Policy - MH Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2019-09-13
WORD_COUNT: 116
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/425010
URL: https://gps.press/sop-data/508.14-att-1/

SUMMARY:
This is the screening form used when inmates are received into GDC facilities to identify mental health needs, suicide risk, psychiatric medication history, and trauma history. Staff complete the form by asking inmates 14 screening questions about their mental health background and current status. Based on responses, inmates may be referred for further mental health evaluation within 14 days, and the form is retained in both medical and mental health files for 10 years.

KEY_TOPICS: mental health screening, reception screening, psychotropic medications, suicide risk, self-harm, psychiatric history, inpatient treatment, outpatient treatment, mental health referral, transgender inmates, substance abuse treatment, head trauma, special education, violent behavior, intra-system transfers, clinical evaluation, inmate intake

ATTACHMENTS:
  1. Mental Health Reception Screen Form (M30-01-01)
     URL: https://gps.press/sop-data/508.14-att-1/
  2. Diagnostic Referral Log
     URL: https://gps.press/sop-data/508.14-att-2/

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