SOP_NUMBER: 508.25-att-5
TITLE: Involuntary Psychiatric Hospital Admission Review (Form M65-01-05)
DIVISION: Unknown
TOPIC_AREA: Mental Health Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2022-08-02
WORD_COUNT: 385
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/290539
URL: https://gps.press/sop-data/508.25-att-5/

SUMMARY:
This form is used by the Mental Health Involuntary Psychiatric Hospitalization Due Process Committee to document and review decisions regarding involuntary psychiatric hospitalization of incarcerated individuals. The form captures offender information, committee member details, hearing officer signatures, and evaluates two key criteria for justifying involuntary hospitalization: whether the offender is mentally ill and presents substantial risk of imminent harm to self or others, or is unable to care for their physical health and safety. The form requires documentation of the committee's reasoning for admission decisions.

KEY_TOPICS: involuntary psychiatric hospitalization, mental health due process, psychiatric hospital admission, mental health committee, hearing officer, offender mental health, imminent harm, psychiatric evaluation, mental health documentation, due process review, Form M65-01-05

ATTACHMENTS:
  1. Certificate of Referral for Emergency Admission (Form M65-01-01)
     URL: https://gps.press/sop-data/508.25-att-1/
  2. Certificate of Mental Condition (Form M65-01-02)
     URL: https://gps.press/sop-data/508.25-att-2/
  3. Emergency Admission Rights of Offenders (Form M65-01-03)
     URL: https://gps.press/sop-data/508.25-att-3/
  4. Notification of Involuntary Hospitalization Due Process Committee Hearing
     URL: https://gps.press/sop-data/508.25-att-4/
  5. Involuntary Psychiatric Hospital Admission Review (Form M65-01-05)
     URL: https://gps.press/sop-data/508.25-att-5/

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FULL TEXT:
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SOP 508.25
Attachment 5

8/2/22

**MH Involuntary Psychiatric Hospitalization Due Process Committee**
**Involuntary Psychiatric Hospital Admission Review**

**Offender’s Information:**


Offender’s Name: __________________________________  ID#: _____________________


Referring Facility: ____________________________________ Date of Referral: ___________


Offender’s Advocate (name/title): _________________________________________________

Offender’s Attorney (name if present): _____________________________________________


State's Advocate (name/title):  ___________________________________________________

Witness(es) (Name/title of presenter questioned):


(name/title):  _________________________________________________________

(name/title):  _________________________________________________________


Committee Members:


(name/title):  _______________________________________________________


(name/title):  _______________________________________________________


(name/title):  _______________________________________________________

Hearing Officer:  __________________________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Mental Health Committee Member: ______________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Medical Committee Member: _____________________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Offender Name/Signature: ___________________________________ I.D. #: _____________


Form no. M65-01-05 Page  1 of 2

Retention Schedule: Completed forms will be given to the Psychiatric Hospital (original), a copy will be given to the
offender, and a copy will be placed in the offender’s mental health file (section 5) and medical file (section 5). At the
end of the offender’s need for mental health services and/or sentence, the mental health file will be placed within the
offender’s health record and retained for 10 years.


SOP 508.25
Attachment 5

8/2/22


|Criteria|Yes|No|
|---|---|---|
|<br>1.<br>The offender is mentally ill, that is, has a disorder of thought or<br>mood which significantly impairs judgment, behavior, capacity<br>to recognize reality or ability to cope with the ordinary demands<br>of life AND the offender presents a substantial risk of imminent<br>harm to themselves or others as manifested by recent overt acts<br>or recent expressed threats which present a probability of injury<br>to themselves or to others.|<br>|<br>|
|<br>2.<br>The offender is mentally ill, that is, has a disorder of thought or<br>mood which significantly impairs judgment, behavior, capacity<br>to recognize reality or ability to cope with the ordinary demands<br>of life AND the offender is unable to care for their own physical<br>health and safety as to create an imminently life endangering<br>crisis.<br>|<br>|<br>|



**Document Committee Reasons for the above decisions** :


_**Note: If criteria #1 and/or #2 are marked yes, then involuntary psychiatric hospitalization is justified.**_


/__________________________
Hearing Officer Signature Date


Form no. M65-01-05 Page  2 of 2

Retention Schedule: Completed forms will be given to the Psychiatric Hospital (original), a copy will be given to the
offender, and a copy will be placed in the offender’s mental health file (section 5) and medical file (section 5). At the
end of the offender’s need for mental health services and/or sentence, the mental health file will be placed within the
offender’s health record and retained for 10 years.