SOP 508.22-att-2: Consent to Sexual Abuse Evaluation

SOP 508.22
Attachment 2

5/3/18

GEORGIA DEPARTMENT OF CORRECTIONS Facility: _________________________________

MENTAL HEALTH SERVICES Name: __________________________________

"Consent to Mental Health Evaluation Following ID#: ____________________________________

Allegation of Suspected Sexual Abuse, Contact or DOB: ___________________________________

Harassment." Race: _________________ Sex: ______________

The Mental Health Staff has been notified that there has been an allegation that you may have been involved in a situation of
sexual abuse, contact and/or harassment.

The Mental Health Staff has a duty to provide you with the opportunity to participate in an evaluation session for determining any
emotional difficulties or need for mental health services resulting from the allegation.

A written report of the evaluation will be filed in your Medical Record and your Mental Health Record. A special Investigator or
Internal Affairs Investigator will have access to the evaluation. Also, access to information in your medical and/or mental health
record may be permitted by law, department procedures, judicial proceedings, accreditation review, professional audits and when
authorized by you with a Release of Information.

According to the results on this evaluation, the Mental Health Staff will recommend further assessment and/or treatment only as
needed. The Mental Health Staff will also be available, if you request or have a need, to accompany you for interviews with the
Special Investigator or Internal Affairs Investigator.

If you have any questions about the limits of confidentiality, please ask for clarification.

Your signature below indicates that you have read this statement or it was read to you, that you understand the limits of
confidentiality within the Department of Corrections and that you agree to receive mental health services.

A copy of this form will be given to you after you have signed it.

___________________________________________________________ ______________________
Offender Name Date

___________________________________________________________ _______________________
Staff Signature/Title Date

Form no. M55-01-02

Retention Schedule: Upon completion, the original form shall be placed in the offender’s medical file (section 5) and a copy will be given to the offender. 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.