SOP_NUMBER: 508.24-att-6 TITLE: Initial Psychiatric/Psychological Evaluation (Form M60-01-06) DIVISION: Mental Health Services TOPIC_AREA: 508 Policy - MH Evaluations/Screenings/Treatment EFFECTIVE_DATE: 2022-08-15 WORD_COUNT: 451 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/290563 URL: https://gps.press/sop-data/508.24-att-6/ 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 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/ ======================================================================== 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 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:** ________ ****************************************************************************** **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 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.