SOP_NUMBER: 508.24-att-1
TITLE: Anxiolytic Informed Consent Form (M60-01-01H)
DIVISION: Mental Health Services
TOPIC_AREA: Mental Health Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2022-08-15
WORD_COUNT: 87
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/290558
URL: https://gps.press/sop-data/508.24-att-1/

SUMMARY:
This is an informed consent form used by the Georgia Department of Corrections when prescribing anxiolytic (anti-anxiety) medications to incarcerated individuals. The form documents that the patient has been informed about and consents to anxiolytic medication treatment. Completed forms are retained in the offender's mental health file for 10 years following the end of mental health services or release.

KEY_TOPICS: anxiolytic medications, anti-anxiety medication, informed consent, mental health medication, medication consent form, psychiatric medication, prisoner medication, GDC mental health, M60-01-01h form

ATTACHMENTS:
  1. Anxiolytic Informed Consent Form (M60-01-01H)
     URL: https://gps.press/sop-data/508.24-att-1/
  2. Abnormal Involuntary Movement Scale (AIMS) Assessment Form
     URL: https://gps.press/sop-data/508.24-att-2/
  3. Lockdown SLU_ACU_CSU Temperature Log
     URL: https://gps.press/sop-data/508.24-att-3/
  4. Medication Information for Hot Weather
     URL: https://gps.press/sop-data/508.24-att-4/
  5. Psychology_Psychiatry Transfer Evaluation
     URL: https://gps.press/sop-data/508.24-att-5/
  6. Initial Psychiatric/Psychological Evaluation (Form M60-01-06)
     URL: https://gps.press/sop-data/508.24-att-6/
  7. Antipsychotic Monitoring Log (M60-01-07) - Weight & Waist Circumference Record
     URL: https://gps.press/sop-data/508.24-att-7/
  8. Instructions for Completing Antipsychotic Weight & Waist Record (M60-01-08)
     URL: https://gps.press/sop-data/508.24-att-8/

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FULL TEXT:
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SOP 508.24
Attachment 1H

8/15/22


**GEORGIA DEPARTMENT OF CORRECTIONS** Facility: _______________________________

**MENTAL HEALTH SERVICES** Name: ________________________________

**Informed Consent for Mental Health Medication** GDC#: _______________________________


DOB: ___________________________

Race: ____________ Sex: ____________
**Anxiolytic Informed Consent**


Form no. M60-01-01h

Retention Schedule: Completed forms 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 10 years.