PREA Mental Health Progress Report

Resident name: Enter name IDOC #: Enter number Facility: Choose Facility.
Mental health staff name: Enter name Associate #: Enter numberPhase 1: PREA Service EvaluationRisk Assessment Verification
☐ Chart review Date completed: Enter date
☐ Risk assessment Date completed: Enter date
☐ Mental health status exam Date completed: Enter date
☐ Recommendation for mental health services Date completed: Enter dateMental Health Recommendations: Enter disposition notes(E-mail form to the following: Clinical Supervisor, Chief
Psychologist, and facility PREA Compliance Manager.)

Phase 2: PREA Service Adjustment

☐ Treatment Completion Verification
Progress report: Enter text(E-mail form to the following: Clinical Supervisor, Chief Psychologist, and facility PREA Compliance Manager.)Phase 3: PREA Service Adjusted☐ Outside
counseling requested: mental health provider (e-mail to Clinical Supervisor)
Disposition: Enter text☐ Outside counseling approved: clinical supervisor (e-mail to Chief Psychologist and facility PREA Compliance Coordinator)
Notes: Enter text☐ Outside counseling extended: Chief Psychologist (email to the facility PREA Compliance Coordinator)
Notes: Enter textPhase 4: Treatment Completed☒ Expanded treatment concluded
Disposition: Enter text(E-mail form to the following: Clinical Supervisor, Chief Psychologist, and facility PREA Compliance Manager.)