SOP 508.21-att-2: Comprehensive Treatment Plan (M50-01-02)

SOP 508.21
Attachment 2

9/23/20

Principal Diagnosis: ________________________________________________________________________________

Other Diagnoses: __________________________________________________________________________________

__________________________________________________________________________________
If diagnosis includes Gender Dysphoria, an intervention is required referring offender to medical for
determination of need for endocrinology services.

[ ] referral to medical is indicated

General medical conditions relevant to mental disorder: _________________________________________________

History of sexual offending: [ ] Yes [ ] No

History of being a victim of physical/sexual abuse: [ ] Yes [ ] No If yes, clinically significant? [ ] Yes [ ] No

Discharge Criteria/Planning: (List criteria that, when met, will allow the offender’s discharge from Mental Health)

Precautions: (List any medical, security or management precautions staff needs to take in the treatment/management of this offender)

Utilization Review:

- Current Level of Care: [ ] Level 2 [ ] Level 3 [ ] Level 4

- Recommended Level of Care: [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4

- Justification: _____________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Signatures :

__________________________________ ________________ ____________ _______________________________
Offender Signature GDC ID# Date Printed/Typed Name

___________________________________________ __________________________ __________________________________
Primary Service Provider Signature Date Printed/Typed Name

___________________________________________ __________________________ __________________________________
Psychologist Signature Date Printed/Typed Name

___________________________________________ __________________________ __________________________________
Psychiatrist /APRN Signature Date Printed/Typed Name

Form no. M50-01-02 Page 1 of 2

Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file. 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 508.21
Attachment 2

9/23/20

|Problems
Goals
Intervention Strategies|Name: ____________________________________
ID#: ______________________________________|
|---|---|
|
Problem #: _________ Problem Description:




|
Problem #: _________ Problem Description:




|
|Goal: [ ] Maintenance [ ] Change
Goal Description:




|Goal: [ ] Maintenance [ ] Change
Goal Description:




|
|Start Date: Target Date: Achieved: Changed:|Start Date: Target Date: Achieved: Changed:|
|Intervention Strategy (Include strengths and weaknesses that impact treatment, actions to be taken, frequency of sessions, and
persons responsible- include referral to medical if indicated):








|Intervention Strategy (Include strengths and weaknesses that impact treatment, actions to be taken, frequency of sessions, and
persons responsible- include referral to medical if indicated):








|

Form no. M50-01-02 Page 2 of 2

Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file. 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.