SOP_NUMBER: 508.23-att-3 TITLE: Specialized Mental Health Treatment Unit Admission Form DIVISION: Clinical Services TOPIC_AREA: 508 Policy - Mental Health Suicide Prevention/ACU/CSU/BTU EFFECTIVE_DATE: 2018-04-27 WORD_COUNT: 290 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/338964 URL: https://gps.press/sop-data/508.23-att-3/ SUMMARY: This form is used to document the admission of offenders to Specialized Mental Health Treatment Units (SMHTU) and Behavioral Therapy Units (BTU) within Georgia correctional facilities. It requires staff to record the offender's clinical justification for admission, history of behavioral and clinical issues, past mental health history including self-injuries, current mental status, clinical assessments, and diagnostic impressions. The form must be completed and signed by SMHTU counselors and psychologists within 24 hours or the next business day, and is retained in the offender's mental health file for ten years. 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 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 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.