SOP 508.23-att-1: Specialized Mental Health Treatment Unit Recommendation Form

SOP 508.23
Attachment 1

4/27/18

GEORGIA DEPARTMENT OF CORRECTIONS

Specialized Mental Health Treatment Unit Recommendation Form

# Date: ________ Offender Name: _____________________ GDC #: ____________________________ DOB: ______________ Race: _________ Referring facility _____________________________

Consideration should be given for placement in the following unit:

Justification for placement (This area must be completed. Attach additional information):

Signatures:

___________________________________________ _____________________________________
Offender – GDC# Printed name

___________________________________________ _____________________________________
Warden/Designee Printed Name

___________________________________________ _____________________________________
Deputy Warden, Care & Treatment Printed Name

______________________________________________________ _____________________________________
Security Representative /Multifunctional C.O. Printed Name

___________________________________________ _____________________________________
Mental Health Unit Manager Printed Name

___________________________________________ _____________________________________
Clinical Director/Psychologist Printed Name

___________________________________________ _____________________________________
Mental Health Counselor Printed Name

___________________________________________ _____________________________________
Activity Therapist Printed Name

Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file (section 8). 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 ten (10)
years.