SOP_NUMBER: 508.21-att-2 TITLE: Comprehensive Treatment Plan (M50-01-02) DIVISION: Mental Health Services TOPIC_AREA: 508 Policy-MH Evaluations/Screenings/Treatment EFFECTIVE_DATE: 2020-09-23 WORD_COUNT: 340 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429773 URL: https://gps.press/sop-data/508.21-att-2/ SUMMARY: This form is used to document comprehensive mental health treatment plans for incarcerated individuals in GDC custody. It requires clinicians to document diagnoses, medical conditions, treatment goals, intervention strategies, level of care recommendations, and discharge planning. The form must be completed and signed by the offender, primary service provider, psychologist, and psychiatrist/APRN, and is retained in the offender's health record for 10 years after treatment completion or sentence completion. KEY_TOPICS: comprehensive treatment plan, mental health treatment, diagnosis, treatment goals, intervention strategies, level of care, discharge criteria, gender dysphoria, sexual offending history, abuse history, treatment planning, mental health services, 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/ ======================================================================== FULL TEXT: ======================================================================== 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.