SOP_NUMBER: 508.24-att-5
TITLE: Psychology_Psychiatry Transfer Evaluation
WORD_COUNT: 187
URL: https://gps.press/sop-data/508.24-att-5/

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 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.