SOP 508.24-att-6: Initial Psychiatric/Psychological Evaluation (Form M60-01-06)

Division:: Mental Health Services
Effective Date:: August 15, 2022
Topic Area:: 508 Policy - MH Evaluations/Screenings/Treatment
PowerDMS:: View on PowerDMS
Length:: 451 words

Summary

This is a standardized form used by GDC to conduct and document initial psychiatric and psychological evaluations for incarcerated individuals. The form captures comprehensive mental health history, current symptoms, substance use, trauma history, violence history, medical conditions, and clinical assessments to determine appropriate mental health service levels and treatment recommendations. It applies to all inmates receiving mental health evaluations and must be completed by psychiatrists or psychologists.

Key Topics

psychiatric evaluation
psychological evaluation
mental health assessment
mental status exam
diagnostic assessment
mental health screening
substance abuse history
trauma history
self-harm risk
mental health diagnosis
treatment planning
mental health level
inmate mental health
psychological evaluation form
chief complaint
medical history

Full Text

SOP 508.24
Attachment 6

8/15/22

Georgia Department of Corrections Facility: ________________________________
Initial Psychiatric/Psychological Evaluation Name: _________________________________
(circle) GDC #: ________________________________

DOB: _________________________________

Date: __________________________ Race: ______________ Sex: _______________

Location: [ ] Private Office [ ] Cell Front
[ ] On-site [ ] Remote (tele-psychiatry/psychology)

Referral Information (including referral source and current medications) and Chief Complaint:

______________________________________________________________________________

Summary of Relevant MH History (include ~~his~~ tory of signs/symptoms since childhood, treatment, medications, etc.):

________________________________________________________________________________________________

______________________________________________________________________________________

Substance Use History: _____________________________________________________________

______________________________________________________________________________

Substance Use Interventions [ ] No [ ] Yes Specify:_________________________________________

Trauma Abuse History: [ ] Yes [ ] No [ ] Sexual [ ] Physical [ ] Psychological

[ ] Not Clinically Relevant [ ] Clinically Relevant

________________________________________________________________________________________________

Biological Family Mental Health History: _______________________________________________

______________________________________________________________________________

Violence History:
Toward Others [ ] Yes [ ] No Toward Animals [ ] Yes [ ] No
Gang Involvement: [ ] Yes [ ] No Fire Setting: [ ] Yes [ ] No
Use of Weapons [ ] Yes [ ] No Other: ________________________________

Form no. M60-01-06 Page 1 of 3

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4) and a copy placed in the medical
file (section 5). 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.

SOP 508.24
Attachment 6

8/15/22

Name: _____________________________ GDC#: _____________________ Date: _________

Medical History: _________________________________________________________________

______________________________________________________________________________

Self-Injury History/Risk Factors: _____________________________________________________

______________________________________________________________________________

Mental Status Exam:
______________________________________________________________

______________________________________________________________________________

Clinical issues related to gender/transgender identification: ______________________________

______________________________________________________________________________

Additional justification for diagnosis: _______________________________________________

______________________________________________________________________________

Principal Diagnosis: ____________________________________________________________________

Other Diagnoses in order of focus of attention and treatment: ___________________________________

_____________________________________________________________________________________

If added to the caseload, Mental Health Diagnosis List and Medical Problem List completed: [ ] Yes

Plan: __________________________________________________________________________

______________________________________________________________________________

Recommended Mental Health Level: [ ] I [ ] II [ ] III [ ] IV

Refer to MD/APRN [ ] Yes [ ] No [ ] N/A

Psychologist/Psychiatrist (circle): _______________________________________________________________

___________________________________ ______________________________ __________
Signature Print Last Name Date

Form no. M60-01-06 Page 2 of 3

SOP 508.24
Attachment 6

8/15/22

Name: ______________________________ GDC#: _____________________ Date: ________

******************
To be completed by psychiatrist/CNS if Needed - (for additional history, use &
attach supplementary form)

Medical Allergy:

______________________________________________________________________________

Relevant Medical Conditions (to include intersex status):
______________________________________________________________________________

______________________________________________________________________________

Additional History:

______________________________________________________________________________

[ ] I acknowledge diagnoses on page two with these considerations:

________________________________________________________________________________________________

Other Plans: ____________________________________________________________________

______________________________________________________________________________

Medication Consent [ ] Yes [ ] N/A ° Labs [ ] Yes [ ] N/A ° AIMS [ ] Yes [ ] NA

Return to Clinic: _________________________

________________________________________ __________________________ ___________
Psychiatrist Signature Print Last Name Date

[ ] There are no additional pages of the initial evaluation ---OR --[ ] There are additional pages attached.

Form no. M60-01-06 Page 3 of 3

Attachments (8)

Anxiolytic Informed Consent Form (M60-01-01H) (87 words)
Abnormal Involuntary Movement Scale (AIMS) Assessment Form (637 words)
Lockdown SLU_ACU_CSU Temperature Log (136 words)
Medication Information for Hot Weather (380 words)
Psychology_Psychiatry Transfer Evaluation (187 words)
Initial Psychiatric/Psychological Evaluation (Form M60-01-06) (451 words)
Antipsychotic Monitoring Log (M60-01-07) - Weight & Waist Circumference Record (190 words)
Instructions for Completing Antipsychotic Weight & Waist Record (M60-01-08) (616 words)

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