SOP 508.23-att-4: Activity Therapy Assessment – for Specialized Mental Health Treatment Program
Summary
Key Topics
- Activity therapy assessment
- mental health treatment
- specialized mental health treatment unit
- leisure therapy
- therapeutic recreation
- anger management
- anxiety treatment
- mood management
- social skills
- inmate strengths and weaknesses
- medical limitations
- treatment recommendations
- activity therapy participation
Full Text
SOP 508.23
Attachment 4
04/27/18
GEORGIA DEPARTMENT OF CORRECTIONS
MH/MR Services
Activity Therapy Assessment – for Specialized Mental Health Treatment Program
Date: _________
Name: _________________ GDC#: ___________________ DOB: ________________ Race: ____ Sex: _____
Facility: ______________ SMHTU Program: ________________________________
Admission Date: __________ Offender’s Level of Care: II III IV (circle)
Original Assessment Date: __________ Annual Review Date: _________
Transfer Review Date _______________________ Facility: __________________________________________
I. Presenting Problems/Issues (list factors such as reasons for referral)
|Initial Assessment/Concerns|Review|
|---|---|
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II. Background Info. (List factors such as age, race, education, relationship with family, previous jobs etc)
|Initial/Yearly|Review|
|---|---|
|Job Skill:|Job Skill:|
|Education:|Education:|
|Relationship w/ Family:|Relationship w/ Family:|
|# of children:|# of children:|
|Military Service:|Military Service:|
III. Medical Precautions/Limitations/Disabilities
|Initial/Yearly|Review|
|---|---|
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|IV. Other Concerns that may affect participat|tion (list factors such as emotional, social & cognitive co|
|---|---|
|Initial/Yearly|Review|
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|V. Inmate’s Strengths & Weakness|Col2|
|---|---|
|Initial/Yearly|Review|
|Strengths:|Strengths:|
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|Weaknesses:|Weaknesses:|
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Page 1 of 2
Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file (section 4) and shall be retained for ten (10) years.
SOP 508.23
Attachment 4
04/27/18
Activity Therapy Assessment
Name: _______________________________________ GDC#: _________________________
VI. Leisure History/Behavior
List the following activities that you enjoy participating in:
|Initial/Yearly|Review|
|---|---|
|Hygiene
|Hygiene
|
|Social Activities
|Social Activities|
|Physical Activities
|Physical Activities|
|Spectator Events
|Spectator Events|
|Creative Arts
|Creative Arts|
|Passive Activities
|Passive Activities|
|Activities w/Family & Friends|Activities w/Family & Friends
|
VII. Activity Therapy Treatment Recommendations/Plan
Inmate will be placed in activity therapy services to improve:
[ ] Leisure Awareness/Education [ ] Social Skills Interaction [ ] Impulsivity
[ ] Aggression [ ] Anger [ ] Anxiety [ ] Mood Management [ ] Other: __________________________
VIII. Level Review
|Activity Therapy Review and Participation Summary|AT Signature|
|---|---|
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________________________ __________ ________________ ________
Activity Therapist Signature/Title Date Offender Signature Date
Review Signatures:
________________________ __________ ________________ ________
Activity Therapist Signature/Title Date Offender Signature Date
Page 2 of 2
Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file (section 4) and shall be retained for ten (10) years.