SOP_NUMBER: 508.23-att-2
TITLE: Consent to Receive Specialized Mental Health Treatment
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy - MH Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2018-04-27
WORD_COUNT: 300
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/353266
URL: https://gps.press/sop-data/508.23-att-2/

SUMMARY:
This is a consent form for incarcerated individuals entering the Specialized Mental Health Treatment Unit. It documents that the person agrees to follow unit rules, work with the treatment team, and pursue their treatment goals. The form explains the unit structure, the process for graduation/discharge, and procedures for withdrawing from the program if the individual changes their mind.

KEY_TOPICS: mental health treatment, specialized mental health unit, consent form, treatment plan, treatment goals, mental health services, correctional mental health, inmate mental health, behavioral treatment unit, treatment team

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/

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FULL TEXT:
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SOP 508.23
Attachment 2

4/27/18


**GEORGIA DEPARTMENT OF CORRECTIONS** Facility: _____________________________________


**MENTAL HEALTH SERVICES** Name: _______________________________________


**"CONSENT TO RECEIVE SPECIALIZED MENTAL** ID#: ____________________ DOB: _______________


**HEALTH TREATMENT”** Race: ________________________ Sex: ___________


You are consenting to receive treatment in the Specialized Mental Health Treatment Unit. This means that
you are willing to abide by the rules of the Unit and Treatment Team working with the Unit. The Treatment
Team consists of the Counselor, Activity Therapist, Multifunctional Correctional Officer, Psychologist,
Psychiatrist, and other designated staff. You are also consenting to follow your Specialized Mental Health
Treatment Unit treatment goals.

Upon graduating from the Specialized Mental Health Treatment Unit, which means you have satisfied your
Specialized Mental Health Treatment Unit treatment goals and the team decided you have accomplished
your treatment goals, you will be returned to your previous living unit or, it may be decided that you will go
to the unit that best suits your particular situation and/or current mental health status.

If during the course of treatment, you decide you do not wish to participate in the Specialized Mental Health
Treatment Unit, put your request in writing. Then, the Specialized Mental Health Treatment Unit Treatment
Team will review your request. You should meet with the Specialized Mental Health Treatment Unit to
discuss the reason(s) you no longer wish to participate. During that time your Treatment Plan may be
revised.

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

__________________________________________________________________  ____________________
Offender Signature                                                                         Date

______________________________________________________________________________  __________________________
Staff Signature                                                                             Date


Retention Schedule: Completed form shall be placed in the offender’s mental health 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 ten (10) years.