SOP_NUMBER: 508.22-att-4
TITLE: Mental Health Initial Sexual Allegation Evaluation
REFERENCE_CODE: VG55-0001
DIVISION: Mental Health Administration
TOPIC_AREA: 508 Policy - MH Administration/Staff/Certification
EFFECTIVE_DATE: 2018-05-03
WORD_COUNT: 616
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/353107
URL: https://gps.press/sop-data/508.22-att-4/

SUMMARY:
This form is used by specially trained mental health counselors to conduct initial evaluations of incarcerated individuals who have made allegations of sexual abuse or assault. The evaluation documents the nature of the allegation, assesses the individual's mental health status and trauma symptoms, and determines whether further mental health treatment or evaluation is needed. The form requires notification of appropriate authorities if the allegation involves staff-on-offender or offender-on-offender abuse and tracks the individual's willingness to cooperate with both mental health and security interviews.

KEY_TOPICS: sexual allegation, sexual abuse, trauma evaluation, mental health assessment, SART notification, staff abuse, offender abuse, mental status exam, clinical assessment, treatment recommendations, consent for treatment, specially trained counselor

ATTACHMENTS:
  1. Sexual Allegation Notification and Evaluation Log
     URL: https://gps.press/sop-data/508.22-att-1/
  2. Consent to Sexual Abuse Evaluation
     URL: https://gps.press/sop-data/508.22-att-2/
  3. Mental Health Sexual Allegation Follow-Up Report
     URL: https://gps.press/sop-data/508.22-att-3/
  4. Mental Health Initial Sexual Allegation Evaluation
     URL: https://gps.press/sop-data/508.22-att-4/

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FULL TEXT:
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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.