SOP_NUMBER: 508.35-att-1 TITLE: Re-Entry Referral Form REFERENCE_CODE: VG85-0001 DIVISION: Mental Health Administration TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification EFFECTIVE_DATE: 2022-08-02 WORD_COUNT: 789 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429788 URL: https://gps.press/sop-data/508.35-att-1/ SUMMARY: This form is used to document and communicate mental health, medical, and re-entry information for offenders being released from GDC custody. The form captures the offender's diagnoses, medications, medical appliances, behavioral history, and re-entry plans, and must be distributed to the offender, their mental health file, probation/parole officers, and the Department of Community Supervision. All sections must be completed, and offenders must receive a 30-day supply of prescribed medications and information about community mental health services upon release. KEY_TOPICS: re-entry referral, mental health discharge, release planning, offender medications, homelessness risk, probation, parole, community supervision, mental health diagnosis, SSI disability, suicidal ideation, homicidal ideation, release of information form ATTACHMENTS: 1. Re-Entry Referral Form URL: https://gps.press/sop-data/508.35-att-1/ 2. Mental Health Services – Offender Release Log URL: https://gps.press/sop-data/508.35-att-2/ 3. Instructions for Completing the Probation-Parole Re-Entry Referral Form (M85-01-03) URL: https://gps.press/sop-data/508.35-att-3/ ======================================================================== FULL TEXT: ======================================================================== 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.