SOP 508.35-att-1: Re-Entry Referral Form

SOP 508.35
Attachment 1

8/2/22

Re-Entry Referral Form
_(Use only if form is not available on Scribe)_

Date of Referral: ___________________________________________ (Provide 30 days notice when possible.)

Offender’s Name/AKA: ___________________________________/__________________________________
(Name on prison record) (Alias or “real” name if different)

GDC ID#: _____________________________________ SSN: ______________________________________

Race: ______ Sex: ______ Date of Birth: ______________________ Release Date:___________________
(Use racial codes: W=White B=Black H=Hispanic A=Asian I=Native American/Native Hawaiian U=Unknown/All Others)

Type of Release: [ ] Sentence Expired, No Probation. [ ] Parole/Reprieve
[ ] Split sentence, Probation Follow Parole. [ ] Probation Only

_________________________________________________ Level of Care: _____________
Chief Probation/Parole Officer

Is the Offender “At Risk” for homelessness after release? [ ] Yes [ ] No

Residence Plan: [ ] Own Home/Apartment [ ] With Relative [ ] Shelter [ ] Homeless

Emergency Contact for Consumer: ________________________________ Contact Phone: _______________

Offender Address: __________________________________________________________________________

Offender Phone: _______________________________ Alternate Phone: ______________________________

Mental Health Diagnosis: Principal Diagnosis: ___________________________________________________

Other Diagnosis: _____________________________________________________

Other Diagnosis: _____________________________________________________

Mental Health Medication: ________________________________________ Dosage: ___________________

Mental Health Medication: ________________________________________ Dosage: ___________________

Mental Health Medication: ________________________________________ Dosage: ___________________

Mental Health Medication: ________________________________________ Dosage: ___________________
********************
Physical Health Diagnosis: [Note: The offender must sign a consent for the release of the physical health
information.]

[ ] Yes (specify]:___________________________________________________________________________

[ ] None [ ] Release of Physical Information Refused by Client.

Form no. M85-01-01 Page 1 of 3

Retention Schedule: Completed forms shall be given to the offender (original), a copy placed in the offender’s mental health file
(section 7) and fax (if not completed on Scribe) to Probation Officer/Parole Officer and Department of Community Supervision
(DCS). 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.

SOP 508.35
Attachment 1

8/2/22

Physical Medication: _____________________________________________ Dosage: ___________________

Physical Medication: _____________________________________________ Dosage: ___________________

Medical Appliances Required: [ ] None [ ] Wheelchair [ ] Crutches [ ] Braces [ ] CPAP [ ] TENS

[ ] Other (specify):_________________________________________________________________________

Re-Entry Referral Form
**********************
Major Offense: ____________________________________________________________________________

-Description of Significant Problems or Behaviors when on Medication:

[ ] None [ ] Injurious to Self [ ] Threatening/Injurious to Staff/Peers
-Description of Significant Problems or Behaviors When Not on Medication :

[ ] None [ ] Injurious to Self [ ] Threatening/Injurious to Staff/Peers

-History of Suicidal Ideation: [ ] Yes [ ] No Suicide Attempts [ ] Yes [ ] No

History of Homicidal Ideation: [ ] Yes [ ] No

Details: __________________________________________________________________________________
******************
Eligible for SSI-Disability: [ ] Yes [ ] No

SSI Disability Application Submitted: [ ] No [ ] Yes (date):____________________________________

Eligible for Medicare/Medicaid: [ ] Yes [ ] No
******************
Referring Facility Name: ____________________________________________________________________

Referring Counselor Name: __________________________________________________________________

Referring Counselor Phone: ____________________________________ Fax: _________________________
******************
NOTE: Provide client with necessary information to contact Community Service Board and a 30-day supply of
ALL prescribed medications.
Distribution:
Original: Mental Health Record (section 7), along with original of Release of Information Form.

Only fax to the following if this form has not been completed in Scribe:
Fax Copy 1: Chief Probation Officer or Chief Parole Officer or both as applicable. Do NOT include supporting
documents with this copy. Ensure the Release of Information Form is attached.

Fax Copy 2: Department of Community Supervision. Do NOT include supporting documents with this copy.
Ensure the Release of Information Form is attached.

Form no. M85-01-01 Page 2 of 3

Retention Schedule: Completed forms shall be given to the offender (original), a copy placed in the offender’s mental health file
(section 7) and fax (if not completed on Scribe) to Probation Officer/Parole Officer and Department of Community Supervision
(DCS). 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.

SOP 508.35
Attachment 1

8/2/22

_Note: All sections must be completed. Write “unknown” or “N/A” where needed, but do not leave any_
_section blank. Do NOT write, “see attached” for any answer; supporting documents are not sent to_
_Probation, Parole or the Department of Community Supervision (DCS). Ensure the Release of Information_
_Form is attached. Ensure Type of Release is the same as indicated on the Release Certificate._

Re-Entry Referral Form
Offender Information Sheet

[ ] An appointment has been made for you with the following mental health provider:

Provider Name: ______________________________________________________________________

Appointment Date: _____________ Time: __________ Phone #: _______________________________

Address: ___________________________________________________________________________

____________________________________________________________________________________

[ ] No appointment has been made. Please call Behavioral Health Link at 1-800-715-4225.

[ ] Probation/Parole Officer Name:____________________________________________________________
(circle)

Phone #: _____________________________

If you cannot keep this appointment or if you wish to decline services and are not required by Probation/Parole
to accept services, please call the above number and inform the Community Service Board.
******************
_Note: If you are on medication, please make sure a supply of your medication is given to you at the time you_
_leave the prison/detention/transition center._
_**********************_

Form no. M85-01-01 Page 3 of 3

Retention Schedule: Completed forms shall be given to the offender (original), a copy placed in the offender’s mental health file
(section 7) and fax (if not completed on Scribe) to Probation Officer/Parole Officer and Department of Community Supervision
(DCS). 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.