SOP_NUMBER: 508.21-att-3
TITLE: Attachment 3 - Comprehensive Treatment Plan Review Form (M50-01-03)
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy - MH Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2020-09-23
WORD_COUNT: 138
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429774
URL: https://gps.press/sop-data/508.21-att-3/

SUMMARY:
This form documents the comprehensive review of an inmate's mental health treatment plan, including current diagnoses, level of care assessment, and progress toward treatment goals. It is used by mental health professionals (psychologists, psychiatrists, and APRNs) to evaluate whether the current level of care is appropriate and to justify any recommended changes. The form must be signed by the offender, service provider, psychologist, and psychiatrist/APRN, and is retained in the offender's mental health file for 10 years after completion of mental health services or sentence completion.

KEY_TOPICS: Comprehensive treatment plan, mental health treatment, level of care, utilization review, diagnoses, treatment goals, mental health assessment, inmate mental health, psychologist evaluation, psychiatrist evaluation, treatment plan review, mental health file

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 3

9/23/20



**Principal Diagnosis: ________________________________________________________________________________**


**Other Diagnoses: __________________________________________________________________________________**


**__________________________________________________________________________________**


**__________________________________________________________________________________**


**General medical condition(s) relevant to mental disorder: ________________________________________________**
**______________________________________________________________________________________________**
**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:** **______________________________________________________________________________**

**___________________________________________________________________________________________**

**___________________________________________________________________________________________**
**__________________________________________________________________________________________**
**Summary of Progress and Changes in Goals, Interventions and Level of Care justification:**


**Due Date of Next Review: _____________**


**__________________________________ _____________ ____________ __________________________________**
**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. M50-01-03 Page 1 of 1

Retention Schedule: Upon completion, this form 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.