SOP_NUMBER: 508.23-att-4
TITLE: Activity Therapy Assessment – for Specialized Mental Health Treatment Program
DIVISION: MH/MR Services
TOPIC_AREA: 508 Policy-MH Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2018-04-27
WORD_COUNT: 319
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/196796
URL: https://gps.press/sop-data/508.23-att-4/

SUMMARY:
This is an assessment form used to evaluate and document incarcerated individuals' participation in activity therapy within specialized mental health treatment programs. The form captures presenting problems, background information, medical precautions, strengths and weaknesses, leisure history, and activity therapy treatment recommendations. It is completed during initial assessment and updated during annual reviews and facility transfers, with completed forms retained in the offender's mental health file for ten years.

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

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 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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|||
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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:**|
|||
|**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<br>|Hygiene<br>|
|Social Activities<br>|Social Activities|
|Physical Activities<br>|Physical Activities|
|Spectator Events<br>|Spectator Events|
|Creative Arts<br>|Creative Arts|
|Passive Activities<br>|Passive Activities|
|Activities w/Family & Friends|Activities w/Family & Friends<br>|


**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.