SOP_NUMBER: 508.23-att-1
TITLE: Specialized Mental Health Treatment Unit Recommendation Form
DIVISION: Unknown
TOPIC_AREA: Mental Health - Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2018-04-27
WORD_COUNT: 134
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/338961
URL: https://gps.press/sop-data/508.23-att-1/

SUMMARY:
This form is used to document and recommend offenders for placement in specialized mental health treatment units within GDC facilities. The form requires justification for the recommended placement and must be signed by multiple staff members including the warden, deputy warden, security representative, mental health unit manager, clinical director, mental health counselor, and activity therapist. Completed forms are retained in the offender's mental health file for ten years after the offender's need for services ends or their sentence is completed.

KEY_TOPICS: mental health treatment units, offender placement, mental health recommendation, ACU, CSU, BTU, specialized housing, mental health services, clinical assessment, multidisciplinary review, mental health file

ATTACHMENTS:
  1. Specialized Mental Health Treatment Unit Recommendation Form
     URL: https://gps.press/sop-data/508.23-att-1/
  2. Consent to Receive Specialized Mental Health Treatment
     URL: https://gps.press/sop-data/508.23-att-2/
  3. Specialized Mental Health Treatment Unit Admission Form
     URL: https://gps.press/sop-data/508.23-att-3/
  4. Activity Therapy Assessment – for Specialized Mental Health Treatment Program
     URL: https://gps.press/sop-data/508.23-att-4/
  5. Specialized Mental Health Treatment Unit (SMHTU) – Orientation to the Program
     URL: https://gps.press/sop-data/508.23-att-5/
  6. Specialized Mental Health Treatment Unit Comprehensive Treatment Plan
     URL: https://gps.press/sop-data/508.23-att-6/
  7. Specialized Mental Health Treatment Unit (SMHTU) Discharge Summary
     URL: https://gps.press/sop-data/508.23-att-7/
  8. Specialized Mental Health Treatment Unit Monthly Report (Monthly Utilization Review)
     URL: https://gps.press/sop-data/508.23-att-8/

========================================================================
FULL TEXT:
========================================================================

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.