SOP 508.22-att-4: Mental Health Initial Sexual Allegation Evaluation

SOP 508.22
Attachment 4

0/00/20

GEORGIA DEPARTMENT OF CORRECTIONS FACILITY:
MENTAL HEALTH INITIAL SEXUAL ALLEGATION
EVALUATION NAME:

On-Site Tele-MH (check one) GDC#: _____________________________________

DOB: _________________________

RACE: _____________SEX: ____________

Specially Trained Counselor's Name/Title: ___________________________________________________________

Relevant Background Information:

l. Correctional History: ___________________________________________________________________________

_______________________________________________________________________________________________

2. Medical: ______________________________________________________________________________________

3. Mental Health History: __________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

4. Prior Victimization/Experiences: __________________________________________________________________

Progress Note:

1. Data: Identify the nature of the allegation and self-reported meaning and impact of the alleged incident. Do NOT

discuss the truth or falsehood of the allegation or reference the name of the alleged perpetrator.

Form no. M55-01-04

Retention Schedule: Original completed form shall be placed in the offender’s medical file (section 5) and in the offender’s mental health file (section 4). 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 508.22
Attachment 4

5/3/18

NAME: __________________________________________ DATE: __________________________

___________________________________________________________________________________________________

2. Assessment: Include a mental status exam and the presence of clinical signs/symptoms of the emotional trauma.

Determine whether the offender is likely to need further evaluation or mental health treatment.

3. Plan: Recommendations for follow-up evaluation and treatment. Note any special housing considerations.

Attach signed "Consent for treatment" form.

Referral form completed for further evaluation: [ ] Yes (Attach a copy of Referral form) [ ] No

Referral form completed for trauma treatment: [ ] Yes (Attach a copy of Referral form) [ ] No

Form no. M55-01-04 Page 2 of 3

Retention Schedule: Upon completion, the original form shall be placed in the offender’s medical file (section 5) and in the offender’s mental health file (section 4). 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 508.22
Attachment 4

5/3/18

NAME: __________________________________________ DATE: __________________________

Questions:
1. Was the allegation of staff on offender abuse? [ ] Yes [ ] No

If "Yes," notify SART and the highest appointed authority of the institution.

Was the allegation of offender on offender abuse? [ ] Yes [ ] No

If "Yes," notify SART and the highest appointed authority of the institution.

Person notified: Date/Time of Notification: ___________________________________

2. Is the offender willing to be interviewed by security? [ ] Yes [ ] No

Does the offender request the specially trained counselor be present during the interview? [ ] Yes [ ] No

3. Did the offender refuse the initial mental health evaluation? [ ] Yes [ ] No

If "Yes," date of the next interview: (To be done within one week.) ____________________________________

4. Was there a second attempt to evaluate the offender? [ ] Yes [ ] No

Did the offender refuse the evaluation on the second attempt? [ ] Yes [ ] No

If "Yes," date of the next interview: (To be done within one week.) Attach a progress note.

5. Did the offender refuse the third attempt to evaluate? [ ] Yes [ ] No

If "Yes," inform the offender that mental health services are available whenever they are desired. Attach
a progress note.

Make sure observations of the offender's mental status are documented in the progress note.
If further evaluation or mental health treatment is recommended and the offender agrees, review the case with the

Mental Health Unit Manager and treatment team.

If the specially trained counselor and the offender see no need for counseling or treatment after the initial

evaluation, inform the offender that further mental health services are available upon request.

Specially Trained Counselor's Signature/Title/Date: _____________________________________________________

Psychologist's Signature (If unavailable, Psychiatrist or APRN): ___________________________________________

Print Name: ___________________________________________________________

Date: (To be signed within two business days.) ______________________________

Form no. M55-01-04 Page 3 of 3

Retention Schedule: Upon completion, the original form shall be placed in the offender’s medical file (section 5) and in the offender’s mental health file (section 4). 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.