SOP 508.35-att-3: Instructions for Completing the Probation-Parole Re-Entry Referral Form (M85-01-03)

SOP 508.35
Attachment 3

8/2/22

Instructions for Completing the Probation-Parole-Re-Entry Referral Form

Following are instructions for completing this form. Read them carefully and refer to
them often until you have mastered the task. Above all else, remember to leave no blank
fields. Also, avoid the use of abbreviations for mental health/medical terms. The
probation and parole officers will probably not understand them.

1. Date of Referral: This should be the date the form is completed and faxed to the
recipients listed under “Distribution.” A minimum of 14 days notice is required
by agreement with the providers, except in cases of a Parole Board action of
immediate release. Thirty days notice should be given with offenders who are
being released on their maximum release date.

2. Offender’s Name/AKA: Regardless of what the offender prefers to be called, the
name on the official facility record should be used. If this is not the offender’s
“real” or preferred name, the “real” or preferred name should be listed after the
“/” mark as an alias.

3. State ID#: If the client is an offender, use the “GDC” number. If the client is a
probation only case, the 15-digit probation case number may be used.

4. SSN: Social Security Number. For 99.9% of offenders, this number is listed in
Scribe. Use the number listed in Scribe rather than relying on the client’s
word/memory whenever possible. Do not leave this field blank. Enter
“unknown” if, and only if, the number cannot be found in Scribe, in the offender’s
record, or be obtained from the client.

5. Race: Use the racial designators from Scribe in this field. These are “W” for
White, “B” for Black, “A” for Asian, “H” for Hispanic, “I” for Native American
or Native Hawaiian, and “O” for all others or if unknown.

6. Sex: Either “M” or “Male” for males and “F” or “Female” for females.

7. Date of Birth: This should also be one listed in the official record. Sometimes
clients are reporting different dates from that listed as official.

8. Release Date: This is the date the offender will be released from the facility.
Enter “N/A” if this referral is being generated by a probation/parole officer rather
than a facility counselor.

9. Type of Release: Check the appropriate box. Verify the correctness of the
information with the record. In 31% of recent cases where “Maxout” was
reported, probation or parole actually followed release. This resulted in the
probation/parole office not receiving a copy of the referral.

Form no. M85-01-03 Page 1 of 4

Retention Schedule: This attachment is instructional only and shall be utilized per the SOP until revised or
obsolete.

SOP 508.35
Attachment 3

8/2/22

10. Chief Probation/Parole Officer: Use the name of the “Chief”, not the actual case
officer, even if this is known.

11. Residence Plan: Check the box that fits closest to the client’s living arrangements
upon release. If he/she has no living arrangements, check homeless.

12. Emergency Contact for Consumer: Name and phone number of the nearest friend
or relative who can be contacted in case of an emergency.

13. Client Address: Address where the client will be living upon release. If homeless
or the specific street address is not known, at least enter the city where the client
plans to reside.

14. Client Phone: Client’s home phone number or shelter phone number. If
homeless, write “No Phone”.

15. Alternate Phone: Phone number of the nearest friend or relative not living with
the client who will be able to take a message for the client. If none, please
indicate “None.”

16. Mental Health Diagnosis: Principal Diagnosis and other diagnosis(es). Do not use
abbreviations like MDD for major depression; the probation and parole officers
may not know what you mean. Do not use the DSM codes for the same reason.
You may shorten diagnoses like “Adjustment Disorder with Depressed Mood” to
“Adjustment Disorder.” Make sure what you write here will be understandable
by people who are not mental health professionals. Physical Health Diagnosis
goes in the section of this form labeled “Physical Health Diagnosis.”

17. Mental Health Medication and Dosage: List each medication and the dosage
prescribed that the client is currently receiving.

18. Physical Health Diagnosis: The law that allows transfer of some mental health
information even against the client’s wishes to provide continuity of care does not
cover physical health information. You must have consent to share physical
health diagnosis and medication. If the client has a physical health diagnosis and
signs a release of information form, check “yes” and specify the diagnosis. If the
client has a physical health diagnosis but refuses to sign a release of information
form, check “yes”, check “Release of Physical Information Refused by Client”
and leave the “specify” line and the physical medication lines blank. If the client
has no physical health diagnosis check “none.”

19 Physical Medication: If the client takes physical health medication and signs a
release of information enter all medications and dosage.

Form no. M85-01-03 Page 2 of 4

Retention Schedule: This attachment is instructional only and shall be utilized per the SOP until revised or
obsolete.

SOP 508.35
Attachment 3

8/2/22

20. Medical Appliances Required: Check the appropriate box. Do not leave blank.
If the client has no medical appliance needs make sure you check “none.” This
information is critical for disability applications. A MH or physical health nurse
can assist with this section, if necessary.

21. Major Offense: List the major crime or crimes for which the client was
convicted. This is public information, so it may be shared.

22. Description of Significant Problems or Behaviors When on Medication: Check
appropriate box and describe problem, unless you check none, for any problems
the client has when they are receiving treatment/medication.

23. Description of Significant Problems or Behaviors When Not on Medication:
Check appropriate box and describe problem, unless you check none, for any
problems the client has when they are NOT receiving treatment/medication.

24. Eligible for SSI-Disability: Indicate “yes” or “no” regarding the client’s potential
eligibility for social security disability benefits. Basically, they are potentially
eligible if they ever contributed to the social security system or has surviving
child or spouse benefits and they have a physical/mental disability.

25. SSI Disability Application Submitted: If the client is potentially eligible for SSI
disability benefits, indicate whether or not a pre-release application for benefits
has been filed and, if “yes” the date it was filed.

26. Eligible for Medicare/Medicaid: Indicate “yes” or “no”.

27. Referring Facility Name: Enter the name of the facility where you work.

28. Referring Counselor Name: Enter your first and last name. Please do not use
only your last name. Make sure you print it, so it is legible; this is not a signature
line.

29. Referring Counselor Phone: Enter the phone number where you can be reached at
work if additional information is needed or if questions arise about an entry on
this form.

30. The provider should contact the Community Service Board (CSB) or other
community agency for and appointment and fax all supporting documents to that
CSB or agency. Ensure you receive the correct fax number (#) to the CSB or
agency where the offender will have their appointment.

31. Note: Provide the client with all necessary information to contact their mental
health provider, as well as the date, time, address, and phone of any appointments
with the Mental Health Clinic that have been set up.

Form no. M85-01-03 Page 3 of 4

Retention Schedule: This attachment is instructional only and shall be utilized per the SOP until revised or
obsolete.

SOP 508.35
Attachment 3

8/2/22

32. Distribution - Original: The original of this form and any release of information
forms are to be placed in section 7 of the client’s mental health record.

33. Distribution - Copy 1: A copy of this form, any release of information forms and
the listed supporting documents are to be faxed to the mental health provider.

34. Distribution - Copy 2: A copy of this form ONLY is to be faxed to the probation
and/or parole office if the client has probation and/or parole to follow. If the
client is being released on a maximum release date, check the file or Scribe to
make sure there are no probated sentences that will begin upon release. This
happens in about 5% of all maximum release cases.

35. Distribution - Copy 3: A copy of this form ONLY is to be faxed to the
Department of Community Supervision (DCS) if it is not completed in Scribe.
The DCS is responsible for tracking the offender if they are assigned to probation
or parole.

36. HELP: Call the Central Office at (478) 992-5855 if you have any questions about
how to complete this form or have questions about whether a referral is required
in a particular case.

Page 3 has been added to provide a format for passing essential information to the
offender who is being referred. Make sure all information needed on page 3 is
completed.

Form no. M85-01-03 Page 4 of 4

Retention Schedule: This attachment is instructional only and shall be utilized per the SOP until revised or
obsolete.