SOP_NUMBER: 508.31-att-8
TITLE: CSU Referral Report (M70-02-08)
DIVISION: Unknown
TOPIC_AREA: 508 Policy - Mental Health Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2019-12-09
WORD_COUNT: 732
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/513943
URL: https://gps.press/sop-data/508.31-att-8/
SUMMARY:
This form is used to document referrals of offenders to Crisis Stabilization Units (CSU) within the Georgia Department of Corrections. It captures offender demographic information, reason for referral (such as suicidal behavior, self-injury, severe mental health symptoms), clinical status at the home facility, and actions taken by the receiving CSU facility. The form is completed in three sections by the sending facility staff, CSU staff, and vendor personnel.
KEY_TOPICS: CSU referral, crisis stabilization unit, suicidal behavior, self-injury, mental health crisis, psychiatric referral, ACU admission, offender mental health, suicide attempt, severe depression, psychosis, mental health assessment, behavioral health, clinical status
ATTACHMENTS:
1. CSU_ACU Daily Nursing Clinical Assessment
URL: https://gps.press/sop-data/508.31-att-1/
2. Crisis Stabilization Unit Psychiatric Admission Form (M70-02-02)
URL: https://gps.press/sop-data/508.31-att-2/
3. Abbreviated Psychiatric Admission for CSU (M70-02-03)
URL: https://gps.press/sop-data/508.31-att-3/
4. Crisis Stabilization Unit Treatment Plan
URL: https://gps.press/sop-data/508.31-att-4/
6. Crisis Stabilization Unit Discharge Summary
URL: https://gps.press/sop-data/508.31-att-6/
7. Crisis Stabilization Unit Admission Log
URL: https://gps.press/sop-data/508.31-att-7/
8. CSU Referral Report (M70-02-08)
URL: https://gps.press/sop-data/508.31-att-8/
9. CSU Discharge Summary Note (Form M70-02-09)
URL: https://gps.press/sop-data/508.31-att-9/
10. Crisis Stabilization Unit (CSU) Admission Cover Page
URL: https://gps.press/sop-data/508.31-att-10/
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FULL TEXT:
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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|
|---|---|---|---|---|
|
**CSU (circle one)**|
**CSU (circle one)**|
**CSU (circle one)**|
**CSU (circle one)**|
**CSU (circle one)**|
|
**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**|
|
**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.**
|
|**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:**
||||
|**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:**
|
|Section 2: To be completed by CSU facility.|Col2|
|---|---|
|**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|
|---|---|---|
|**Rec'd _____________ Time: ___________AM/PM**
** (date)**|**Logged: _________________**
** (date)**|**Clerical:**
|
|**Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission**
|**Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission**
|**Admission Rating: [ ] Appropriate Admission [ ] Questionable Admission [ ] Inappropriate Admission**
|
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.