SOP 508.23-att-3: Specialized Mental Health Treatment Unit Admission Form
Summary
Key Topics
- mental health treatment unit
- SMHTU admission
- behavioral therapy unit
- BTU admission
- specialized treatment
- mental health assessment
- clinical behavior
- diagnostic impressions
- mental status evaluation
- self-injury history
- treatment team
- offender mental health
- admission documentation
Full Text
SOP 508.23
Attachment 3
4/27/18
|SPECIALIZED MENTAL HEALTH
TREATMENT UNIT
ADMISSION FORM|Offender Identification
Facility: ____________________________________
Name: ______________________________________
GDC ID#: ________________ DOB: ________________
Race: _______________ Sex: __________________|
|---|---|
|
Clinical Behavior Justification or Reason for Admission:
History of Present Clinical Behaviors or Resistance to Customary Treatment Services and
Disciplinary Sanctions:
Past Clinical Behaviors History:(Be sure to include a summary of your chart review, disciplinary history, and self-
injuries)
Mental Status:
|
Clinical Behavior Justification or Reason for Admission:
History of Present Clinical Behaviors or Resistance to Customary Treatment Services and
Disciplinary Sanctions:
Past Clinical Behaviors History:(Be sure to include a summary of your chart review, disciplinary history, and self-
injuries)
Mental Status:
|
Page 1 of 2
Retention Schedule: Completed forms 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.
SOP 508.23
Attachment 3
4/27/18
|BEHAVIORAL THERAPY UNIT
ADMISSION FORM|Offender Identification
Facility: _______________________________________
Name: ________________________________________
ID#: ________________ DOB: ___________________
Race: _______________ Sex: ____________________|
|---|---|
|Assessment:
Diagnostic Impressions:
Primary: __________________________________________________________________
Other: ____________________________________________________________________
Other: ____________________________________________________________________
Other: ____________________________________________________________________
(TO BE COMPLETED WITHIN 24 HOURS OR NEXT BUSINESS DAY)
_____________________________ _______________________________
SMHTU Counselor's Signature Printed/Typed Name Date
________________________________________ ___________________________________________
SMHTU Psychologist’s Signature Printed/Typed Name Date
|Assessment:
Diagnostic Impressions:
Primary: __________________________________________________________________
Other: ____________________________________________________________________
Other: ____________________________________________________________________
Other: ____________________________________________________________________
(TO BE COMPLETED WITHIN 24 HOURS OR NEXT BUSINESS DAY)
_____________________________ _______________________________
SMHTU Counselor's Signature Printed/Typed Name Date
________________________________________ ___________________________________________
SMHTU Psychologist’s Signature Printed/Typed Name Date
|
|Other SMHTU Treatment Team members’ signatures:
|Other SMHTU Treatment Team members’ signatures:
|
|||
Page 2 of 2
Retention Schedule: Completed forms 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.