SOP_NUMBER: 508.15-att-1
TITLE: Mental Health Evaluation for Services (Form M31-01-01)
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy - MH Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2022-08-15
WORD_COUNT: 795
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/350765
URL: https://gps.press/sop-data/508.15-att-1/
SUMMARY:
This form is used by the Georgia Department of Corrections to conduct comprehensive mental health evaluations of incarcerated individuals. It documents presenting problems, psychiatric history, substance use, trauma and abuse history, medical conditions, social history, and other relevant clinical information to assess an offender's mental health service needs. The evaluation can be conducted on-site, via telemedicine, in an office setting, or at a cell front, and the resulting records are retained in the offender's health file for 10 years after the need for mental health services ends.
KEY_TOPICS: mental health evaluation, psychiatric assessment, inmate mental health, suicide risk, self-harm, substance abuse history, trauma history, abuse history, mental health screening, depression, anxiety, psychosis, medication history, treatment history, offender health services
ATTACHMENTS:
1. Mental Health Evaluation for Services (Form M31-01-01)
URL: https://gps.press/sop-data/508.15-att-1/
2. Mental Status Evaluation (Attachment 2)
URL: https://gps.press/sop-data/508.15-att-2/
3. Authorization for Release of Information (Mental Health Services)
URL: https://gps.press/sop-data/508.15-att-3/
4. Parole Evaluation Log (Form M31-01-04)
URL: https://gps.press/sop-data/508.15-att-4/
5. Requested Records Log
URL: https://gps.press/sop-data/508.15-att-5/
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FULL TEXT:
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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.