SOP_NUMBER: 508.21-att-1
TITLE: Initial Treatment Plan
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy-MH Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2020-09-23
WORD_COUNT: 262
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429771
URL: https://gps.press/sop-data/508.21-att-1/

SUMMARY:
This form is used to document the initial mental health treatment plan for incarcerated individuals upon entry into the Georgia Department of Corrections mental health system. It captures clinical impressions, safety precautions, housing level, and identifies problems, goals, and treatment strategies for each offender. The form requires a primary care provider signature and establishes a due date for the comprehensive treatment plan per SOP 508.21.

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

ATTACHMENTS:
  1. Initial Treatment Plan
     URL: https://gps.press/sop-data/508.21-att-1/
  2. Comprehensive Treatment Plan (M50-01-02)
     URL: https://gps.press/sop-data/508.21-att-2/
  3. Attachment 3 - Comprehensive Treatment Plan Review Form (M50-01-03)
     URL: https://gps.press/sop-data/508.21-att-3/

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FULL TEXT:
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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<br>      psychotropic medications.<br> <br>[  ] Offender recently treated for<br>      MH symptoms but denied<br>     current distress and does not<br>     want MH services.<br> <br>[  ] Offender reported the following<br>      symptoms:  _______________<br>       ________________________<br>       ________________________<br>       ________________________<br> <br>[  ] The following functional<br>      impairments are reported or<br>      observed: _________________<br>       _________________________<br>       _________________________<br>       _________________________<br> <br> [  ] Other:____________________<br>       _________________________<br>       _________________________|[  ] Determine need for MH<br>      treatment.<br> <br>[  ] Reduce/eliminate frequency,<br>     duration and severity of<br>     distressing symptoms.<br> <br>[  ] Stable adjustment to<br>      incarceration.<br> <br>[  ] Behavioral improvement in the<br>      following areas: ___________<br>      _________________________<br>      _________________________<br>      _________________________<br> <br>[  ] Other: ____________________<br>**       _________________________**<br>**       _________________________**|[  ] Refer to psychologist for<br>     evaluation.<br> <br>[  ] Refer to psychiatrist/APRN for<br>      evaluation/medication follow-<br>      up.<br> <br>[  ] Assigned primary service<br>      provider will meet with<br>      offender per SOP or as needed,<br>      with treatment interventions to<br>      include the following: _______<br>      _________________________<br>      _________________________<br>      _________________________<br> <br>[  ] Refer to ACU/CSU for<br>      stabilization.<br> <br>[  ] Consider D/C to Level I status<br>      in ____ days per SOP.<br> <br>[  ] Other: ____________________<br>       _________________________<br>       _________________________<br>|



**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.