SOP 508.29-att-2: Suicide Precautions Treatment Plan

SOP 508.29
Attachment 2

7/1/20

|Suicide Precautions
Initial Treatment Plan
[not recommended for use if placed in ACU or CSU]|Identification
Facility: _______________________________________
Offender: ______________________________________
GDC ID#: ______________________________________
DOB: __________________________________________
Race: ______________ Sex: ______________________|
|---|---|
|Date initiated: _________
|Date initiated: _________
|
|Problem: [ ] Environmental / Contextual Factors


[ ] Suicide Risk Factors
Specify: _____________________________________________________
________________________________________________________
________________________________________________________

[ ] Self Injurious Behavior
Specify: ___________________________________________________

[ ] Suicide Attempt
Specify: ___________________________________________________
|Problem: [ ] Environmental / Contextual Factors


[ ] Suicide Risk Factors
Specify: _____________________________________________________
________________________________________________________
________________________________________________________

[ ] Self Injurious Behavior
Specify: ___________________________________________________

[ ] Suicide Attempt
Specify: ___________________________________________________
|
|Goal:(a) Physical Safety
(b) Decrease in suicide risk factors
(c) Increase in protective factors / level of care
(d) Return to daily routine/activities
|Goal:(a) Physical Safety
(b) Decrease in suicide risk factors
(c) Increase in protective factors / level of care
(d) Return to daily routine/activities
|
|
Revisions should be made to the comprehensive treatment plan’s goals and interventions.

Clinical Interventions:

[ ] Individual Counseling
starting date: ___________________________ frequency: _____________________________
person responsible: ______________________

[ ] Placement in Suicide Prevention Group
starting date: ____________________________ person responsible: ______________________

[ ] Activity Therapy
specify: ________________________________ frequency: ______________________________
person responsible: _______________________

[ ] Psychotropic Medication(change or addition)
specify: ________________________________ person responsible: _______________________


|
Revisions should be made to the comprehensive treatment plan’s goals and interventions.

Clinical Interventions:

[ ] Individual Counseling
starting date: ___________________________ frequency: _____________________________
person responsible: ______________________

[ ] Placement in Suicide Prevention Group
starting date: ____________________________ person responsible: ______________________

[ ] Activity Therapy
specify: ________________________________ frequency: ______________________________
person responsible: _______________________

[ ] Psychotropic Medication(change or addition)
specify: ________________________________ person responsible: _______________________


|
|
________________________________________ ___________________________ _______________________ ________
Offender’s/Detainee’s Signature Date MH Counselor’s Name (Print) Signature Date


Reviewed by:

________________________________________ ____________________________________ _____________________________ _______________
Upper Level Provider’s Name (Print) Signature Title Date

|
________________________________________ ___________________________ _______________________ ________
Offender’s/Detainee’s Signature Date MH Counselor’s Name (Print) Signature Date


Reviewed by:

________________________________________ ____________________________________ _____________________________ _______________
Upper Level Provider’s Name (Print) Signature Title Date

|

Form no. M69-01-02 Page 1 of 1

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 2). 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.