SOP_NUMBER: 508.29-att-2
TITLE: Suicide Precautions Treatment Plan
WORD_COUNT: 299
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/407632
URL: https://gps.press/sop-data/508.29-att-2/
ATTACHMENTS:
1. Suicide Risk Assessment Instrument
URL: https://gps.press/sop-data/508.29-att-1/
2. Suicide Precautions Treatment Plan
URL: https://gps.press/sop-data/508.29-att-2/
3. Suicide Precautions Rounds
URL: https://gps.press/sop-data/508.29-att-3/
4. Suicide Precautions Log
URL: https://gps.press/sop-data/508.29-att-4/
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FULL TEXT:
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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.