SOP 508.31-att-8: CSU Referral Report (M70-02-08)

SOP 508.31
Attachment 8

12/9/19

Georgia Department of Corrections Facility: _______________________________________________

CSU Referral Report Offender: _______________________________________________

**Housing at time of Incident? (circle one) GDC ID #: ______________________________________________

GP SLU ISO/SEG DOB: _______________________________Age: ______________

Other: ____________________________ Race: _________________________ Sex: ___________________

|Section 1: To be completed by sending facility Home Facility: _________________________________________|Col2|Col3|Col4|Col5|
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CSU (circle one)|
CSU (circle one)|
CSU (circle one)|
CSU (circle one)|
CSU (circle one)|
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ASMP Baldwin GSP LASP GDCP Phillips Valdosta|
ASMP Baldwin GSP LASP GDCP Phillips Valdosta|
ASMP Baldwin GSP LASP GDCP Phillips Valdosta|
ASMP Baldwin GSP LASP GDCP Phillips Valdosta|
ASMP Baldwin GSP LASP GDCP Phillips Valdosta|
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Contact Person|
Title|
Title|
Phone Number|
Contact /Pager Number|
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|Reason for Referral (indicate the Primary reason for referral by checking only one of the following)|Reason for Referral (indicate the Primary reason for referral by checking only one of the following)|Reason for Referral (indicate the Primary reason for referral by checking only one of the following)|Reason for Referral (indicate the Primary reason for referral by checking only one of the following)|Reason for Referral (indicate the Primary reason for referral by checking only one of the following)|
|[ ] Suicidal Behavior/Attempt [ ]Self-injurious Behavior [ ] Severe Psychosis [ ] Suicidal Threats/Statements
[ ] Severe Depression [ ] Severe Mania [ ] Suicidal Thoughts/ideation [ ] Severe Aggression
[ ] Other (describe below)|[ ] Suicidal Behavior/Attempt [ ]Self-injurious Behavior [ ] Severe Psychosis [ ] Suicidal Threats/Statements
[ ] Severe Depression [ ] Severe Mania [ ] Suicidal Thoughts/ideation [ ] Severe Aggression
[ ] Other (describe below)|[ ] Suicidal Behavior/Attempt [ ]Self-injurious Behavior [ ] Severe Psychosis [ ] Suicidal Threats/Statements
[ ] Severe Depression [ ] Severe Mania [ ] Suicidal Thoughts/ideation [ ] Severe Aggression
[ ] Other (describe below)|[ ] Suicidal Behavior/Attempt [ ]Self-injurious Behavior [ ] Severe Psychosis [ ] Suicidal Threats/Statements
[ ] Severe Depression [ ] Severe Mania [ ] Suicidal Thoughts/ideation [ ] Severe Aggression
[ ] Other (describe below)|[ ] Suicidal Behavior/Attempt [ ]Self-injurious Behavior [ ] Severe Psychosis [ ] Suicidal Threats/Statements
[ ] Severe Depression [ ] Severe Mania [ ] Suicidal Thoughts/ideation [ ] Severe Aggression
[ ] Other (describe below)|
|Brief Description of Reason for Referral (include description of any injury to self or others)|Brief Description of Reason for Referral (include description of any injury to self or others)|Brief Description of Reason for Referral (include description of any injury to self or others)|Brief Description of Reason for Referral (include description of any injury to self or others)|Brief Description of Reason for Referral (include description of any injury to self or others)|
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|Target Symptoms and severity from last psychiatric progress note.
|Target Symptoms and severity from last psychiatric progress note.
|Target Symptoms and severity from last psychiatric progress note.
|Target Symptoms and severity from last psychiatric progress note.
|Target Symptoms and severity from last psychiatric progress note.
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|Clinical Status (at home facility)|Clinical Status (at home facility)|Medications (prior to crisis)|Medications (prior to crisis)|Medications (prior to crisis)|
|Mental Health Level from home facility (circle one)
1 2 3 4 5|Mental Health Level from home facility (circle one)
1 2 3 4 5||||
|Most Recent Diagnosis:
|Most Recent Diagnosis:
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|Level of Functioning (prior to this crisis).
[ ] Good [ ] Fair [ ] Poor|Level of Functioning (prior to this crisis).
[ ] Good [ ] Fair [ ] Poor||||
|Signature/Title of person completing Section 1 of this form:
|Signature/Title of person completing Section 1 of this form:
|Signature/Title of person completing Section 1 of this form:
|Signature/Title of person completing Section 1 of this form:
|Signature/Title of person completing Section 1 of this form:
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|Section 2: To be completed by CSU facility.|Col2|
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|Clinical Status in CSU the morning this document is faxed.|Clinical Status in CSU the morning this document is faxed.|
|[ ] Restraints [ ] Sedated [ ] Agitated [ ] Disoriented [ ] Oriented [ ] Angry [ ] Sleeping [ ] Threatening
[ ] Nervous [ ] Calm [ ] Hallucinating [ ] Other|[ ] Restraints [ ] Sedated [ ] Agitated [ ] Disoriented [ ] Oriented [ ] Angry [ ] Sleeping [ ] Threatening
[ ] Nervous [ ] Calm [ ] Hallucinating [ ] Other|
|Action taken by CSU Facility: [ ] Admitted to CSU [ ] Admitted to ACU [ ] Other
|Action taken by CSU Facility: [ ] Admitted to CSU [ ] Admitted to ACU [ ] Other
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|Admit Date:
|Admit Time:
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|If admitted, expected length of stay: [ ] less than 24 hours [ ] 1 day [ ] 2 days [ ] 3 days [ ] 4 days [ ] 6 or more days
|If admitted, expected length of stay: [ ] less than 24 hours [ ] 1 day [ ] 2 days [ ] 3 days [ ] 4 days [ ] 6 or more days
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|Signature/Title of person completing Section 2 of this form:
|Signature/Title of person completing Section 2 of this form:
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|Section 3: Vendor Internal Use Only|Col2|Col3|
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|Rec'd _____________ Time: ___________AM/PM
(date)|Logged: _________________
(date)|Clerical:
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|Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission
|Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission
|Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission
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Form no. M70-02-08 Page 1 of 1

Retention Schedule: Upon completion, this form shall be placed in the offender’s medical file (Infirmary Section with CSU/ACU packets) and retained for ten (10)
years.