SOP 508.21-att-1: Initial Treatment Plan
Summary
Key Topics
- mental health treatment plan
- initial assessment
- clinical impressions
- treatment goals
- treatment strategies
- psychotropic medications
- mental health symptoms
- functional impairment
- behavioral health
- ACU
- crisis stabilization
- segregation
- protective custody
- mental health services
- inmate mental health
- offender treatment
Full Text
SOP 508.21
Attachment 1
9/23/20
GEORGIA DEPARTMENT OF CORRECTIONS INSTITUTION: _____________________________
MENTAL HEALTH SERVICES NAME: ____________________________________
INITIAL TREATMENT PLAN GDC ID#: __________________________________
DOB: __________________
DATE: ________________ SEX: __________________
RACE: _________________
Clinical Impressions: __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Precautions: [ ] General Precautions [ ] History of assaultive behavior [ ] History of SIB
[ ] Other: ___________________________________________________
Level of Impairment : [ ] Level II - GP [ ] Level III - SLU [ ] Level IV - SLU [ ] Level V - (ACU/CSU)
Current Housing: [ ] Diagnostics [ ] General Population
[ ] Acute Care Unit [ ] Crisis Stabilization Unit
[ ] Segregation/Isolation [ ] TIER circle: I II III
[ ] Protective Custody
|Problems|Goals|Treatment Strategies|
|---|---|---|
|[ ] Offender arrived on
psychotropic medications.
[ ] Offender recently treated for
MH symptoms but denied
current distress and does not
want MH services.
[ ] Offender reported the following
symptoms: _______________
________________________
________________________
________________________
[ ] The following functional
impairments are reported or
observed: _________________
_________________________
_________________________
_________________________
[ ] Other:____________________
_________________________
_________________________|[ ] Determine need for MH
treatment.
[ ] Reduce/eliminate frequency,
duration and severity of
distressing symptoms.
[ ] Stable adjustment to
incarceration.
[ ] Behavioral improvement in the
following areas: ___________
_________________________
_________________________
_________________________
[ ] Other: ____________________
_________________________
_________________________|[ ] Refer to psychologist for
evaluation.
[ ] Refer to psychiatrist/APRN for
evaluation/medication follow-
up.
[ ] Assigned primary service
provider will meet with
offender per SOP or as needed,
with treatment interventions to
include the following: _______
_________________________
_________________________
_________________________
[ ] Refer to ACU/CSU for
stabilization.
[ ] Consider D/C to Level I status
in ____ days per SOP.
[ ] Other: ____________________
_________________________
_________________________
|
Comprehensive Treatment Plan Due Date (based on SOP 508.21): ______________________
`___________________________` ____________________________________
Primary Care Provider Signature/Title Printed/Typed Name
Form no. M50-01-01 Page 1 of 1
Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 2). 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.