SOP_NUMBER: 508.35-att-3 TITLE: Instructions for Completing the Probation-Parole Re-Entry Referral Form (M85-01-03) REFERENCE_CODE: VG85-0001 DIVISION: Mental Health Administration/Staff/Certification TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification EFFECTIVE_DATE: 2022-08-02 WORD_COUNT: 1490 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/1025455 URL: https://gps.press/sop-data/508.35-att-3/ SUMMARY: This document provides detailed instructions for facility counselors completing the Probation-Parole Re-Entry Referral Form (M85-01-03) when releasing offenders into the community. The form ensures that probation and parole officers receive critical mental health, physical health, and personal information about individuals being released to facilitate continuity of care. Staff must complete all fields without abbreviations and provide at least 14 days' notice to community providers before release. KEY_TOPICS: re-entry referral, probation and parole, release planning, mental health diagnosis, medication management, community transition, discharge planning, offender information, form completion, continuity of care, SSI disability, medical appliances, release conditions 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 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.