SOP 508.15-att-1: Mental Health Evaluation for Services (Form M31-01-01)

SOP 508.15
Attachment 1

8/15/22

GEORGIA DEPARTMENT OF CORRECTIONS Facility: _____________________________________

MENTAL HEALTH SERVICES Name: ______________________________________

MENTAL HEALTH EVALUATION FOR SERVICES GDC #:______________________________________

On-Site ___ Tele-MH ___ (check one) DOB: _______________________________________

In Office ___ Cell Front___ (check one) Race: _________________ Sex: _________________

1. Presenting Problem
Description of current symptoms: _______________________________________________________________
Offender's statement of problem: _______________________________________________________________
___________________________________________________________________________________________

2. History of Offender
A. Past Psychiatric History
(1) Treatment

|Age|Setting
Inpatient Outpatient|Col3|Diagnosis|Medication/Treatmen
t|Response|
|---|---|---|---|---|---|
|||||||
|||||||
|||||||

(2 ) Non-Suicidal Self-Injury and/or Suicide Attempts

|Age|Setting|Method|Precipitants|
|---|---|---|---|
|||||
|||||
|||||

( 3) Assaultive Behavior

|Age|Description/Circumstances|
|---|---|
|||
|||
|||

(4) Drug and Alcohol History/Treatment

|Substance|Date of First
Use|Amount Used|Frequency of
Use|Date of Last Use|Treatment|
|---|---|---|---|---|---|
|||||||
|||||||
|||||||

|(5)|Family History of Mental Illness|Col3|
|---|---|---|
|Family Member|Diagnosis|Treatment/Medications|
||||
||||
||||

3. Abuse History (Victimization)

A. Physical Abuse

Form M31-0001 Page 1 of 3

Original Mental Health Record (section 4), Copy: Medical Record (section 5) – Retention Schedule: 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.

SOP 508.15
Attachment 1

8/15/22

(1) When you were a child/adult did anyone ever harm you in a way that caused physical pain, left
marks on your body, and/or required medical attention? [ ] No [ ] Yes
If yes, answer the following questions:
-Who was the abuser (relationship)? _______________________________________________
-How did you react when it happened (any problems)? ________________________________
-Do you still experience problems? What do you think about it now? _____________________
___________________________________________________________________________

B . Sexual Abuse
( 1) Did anyone ever touch your private parts when you were a child/adult? [ ] No [ ] Yes
If yes, answer the following questions:
-Who was the abuser (relationship)? _______________________________________________
-How did you react when it happened (any problems)? ________________________________
-Do you still experience problems? What do you think about it now? ____________________
____________________________________________________________________________

C. Psychological Abuse and Neglect
(1) When you were a child/adult did anyone ever verbally abuse you? [ ] No [ ] Yes
(2) As a child did you ever feel the adults in your life neglected to provide for your basic needs?

[ ] No [ ] Yes
D. Physical/Sexual/ Psychological Abuse and Neglect
(1) If there is a positive history of victimization, is it clinically relevant? [ ] No [ ] Yes

4. Abuse History (perpetration)
A. Did you ever cause physical harm to a child/adult? [ ] No [ ] Yes
B. Did you ever have sexual contact with a child? [ ] No [ ] Yes
C. Did you ever have non-consensual sex with an adult? [ ] No [ ] Yes

5. Other Traumatic Experiences [ ] No [ ] Yes
A. Identify and describe: _________________________________________________________________
___________________________________________________________________________________
B. Clinical relevance:____________________________________________________________________
___________________________________________________________________________________

6 . Medical History
A. Chronic medical condition(s): ___________________________________________________________
B. Acute Illness(es) (Illness/date): __________________________________________________________
C. Head injury? [ ] No [ ] Yes [ ] without loss of consciousness [ ] with loss of consciousness
D. Current non-psychotropic medication(s): __________________________________________________
____________________________________________________________________________________
E. Intersex: [ ] No [ ] Yes If yes, identify any concerns: __________________________________
____________________________________________________________________________________

7. Transgender Identification
A. Do you identify as transgender? [ ] No [ ] Yes
B. Do you have any symptoms or concerns associated with this identification? [ ] No [ ] Yes
If yes, explain:_______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________

8. Social History
A. Family/Support Network
(1) Consisting of whom?

Form M31-0001 Page 2 of 3

Original Mental Health Record (section 4), Copy: Medical Record (section 5) – Retention Schedule: 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.

SOP 508.15
Attachment 1

8/15/22

(2) Current Family Support: __________________________________________________________
(3) History of involvement of Department of Family & Children Services / placement in foster care?
______________________________________________________________________________
B. Marital and Relationship History
(1) Current significant other?
(2) Nature of relationship? ___________________________________________________________
(3) Past marriages and significant relationships (number of marriages/relationships and nature)?
______________________________________________________________________________
C. Child(ren) (list names, age/sex, and current care provider): _____________________________________
____________________________________________________________________________________
D. Occupational History/Work Skills: ________________________________________________________
____________________________________________________________________________________

9. Military Experience
A. Branch and Dates of Service:
B. Type of Discharge: _____________________________________________________________________
C. Combat experience: [ ] No [ ] Yes If yes, identify where and when: ______________________
____________________________________________________________________________________
_____________________________________________________________________________________
Identify any clinical or medical symptoms secondary to combat experience: _______________________
_____________________________________________________________________________________

10. Educational History: Highest grade? _____Special Education? ______Technical Training? _____GED? _____

11. Criminal/Legal History
A. Current conviction and precipitating factors: _________________________________________________
_____________________________________________________________________________________
B. Sentence: ____________________________________________________________________________
C. Previous conviction(s) as adult/juvenile: ____________________________________________________

12. Recommendations:
For additional evaluations: [ ] Psychiatric Evaluation [ ] Psychological Evaluation
[ ] Developmental Disability Evaluation [ ] Other: ______________________

13. Precautions: Suicidal [ ] Yes [ ] No Homicidal [ ] Yes [ ] No Psychotic [ ] Yes [ ] No

14. Clinical Observations:
___ ________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

15. Mental Health Level of Care Recommendations:

[ ] Level I, no need for mental health services

[ ] Level II, Mental Health outpatient services (placement in general population)

[ ] Satellite Facility [ ] Extended Care Facility [ ] Full Service Facility with Supportive Living Unit

[ ] Level III, Mental Health Supportive Living Unit Services (placement in a Supportive Living Unit)

[ ] Level IV, Mental Health Intensive Supportive Living Services (placement in a Supportive Living Unit)

[ ] Level V, Crisis Stabilization Services (placement in Crisis Stabilization Infirmary Unit)

_____________________________________________________ ________________________________
Evaluator/Title Date

_____________________________________________________________ ____________________________________
Reviewer/Title Date

Form M31-0001 Page 3 of 3

Original Mental Health Record (section 4), Copy: Medical Record (section 5) – Retention Schedule: 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.