SOP 508.24-att-5: Psychology_Psychiatry Transfer Evaluation
Full Text
SOP 508.24
Attachment 5
8/15/22
GEORGIA DEPARTMENT OF CORRECTIONS Facility: ___________________________
Name: _____________________________
PSYCHOLOGY/PSYCHIATRY ID#: ______________________________
TRANSFER EVALUATION [ ] Onsite [ ] Tele-MH Race: Sex:__________
This inmate transferred from _______________________ on ___________________ as a MH Level (circle one) II III IV
Diagnosis : Offender Records indicate the Principal Diagnosis is: ______________________________________________________
Additional Diagnoses are: ___________________________________________________________________________________
MH Medications : (Circle one) No Medications Involuntary Medications Voluntary Medications (list below)
Current MH Medications:_____________________________________________________________________________________
Medical : Significant Physical Health Diagnoses (Circle one) No Yes (If yes, please list clinically significant below)
___________________________________________________________________________________________________________
Self-Injurious Behavior History (Circle one) No Yes (If yes, please list clinically significant below)
___________________________________________________________________________________________________________
Summary of Mental Health History (pre- and post- incarceration) : _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Current Mental Health Status: _________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Target Symptoms and Ratings (0-5): 1.__________________( ); 2.____________________( ); 3.____________________( )
Diagnosis (es) Change: [ ] No (Sign/Date Diagnosis List) [ ]Yes (Complete New Diagnosis List, explain below & update Problem List)
Explanation: _______________________________________________________________________________________________
Plan: ______________________________________________________________________________________________________
_____________________________________________________________________________ Return to Clinic: _______________
______________________________________________ ____________________________________ ____________________
Signature & Title Print Name Today’s Date
Form no. M60-01-05
Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4). 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.