Disciplinary Mental Health Recommendation

MENTAL HEALTH DOR RECOMMENDATION
INMATE NAME IDOC # FACILITY
OFFENSE DATE OFFENSE DESCRIPTION CLINICIAN
Is there a documented history of significant mental illness that would or could
impair decision making and/or reality testing?
Yes ☐ No ☐
Is the inmate presently prescribed medication for mental health issues? Yes ☐ No ☐
**If yes; is the inmate compliant with their medications? Yes ☐ No ☐
Did the inmate experience a significant increase of stressors prior to the incident? Yes ☐ No ☐
Was there a documented increase in mental health symptoms prior to the incident? Yes ☐ No ☐
Was mental illness a contributing factor? Yes ☐ No ☐
Was mental illness a mitigating factor? Yes ☐ No ☐
Was mental illness a factor in this incident?Yes ☐ No ☐
Should a clinician be present during the DOR hearing to assist with the process? Yes ☐ No ☐
Recommendations (if applicable)
CLINICIAN SIGNATURE DATE OF RECOMMENDATION