Based on the initial mental health assessment, inmates in need of further evaluation for initiation or continuation of medication, diagnostic clarity, or who are otherwise complicated in their presentation, receive a comprehensive mental health assessment by a Psychiatrist or mid-level provider.  The need for this level of assessment is determined by a Mental Health Professional.

The Comprehensive Mental Health Assessment includes and builds on the baseline assessment established by the Initial Treatment Plan and is documented in a designated area of the same form. In addition to further clarifying important clinical history, there is an emphasis on the mental status examination, suicide risk identification, diagnostic clarification, and, when psychotropic medication is thought to be appropriate, documentation of a discussion of risks, benefits, indications and alternatives available to the offered treatment.  When necessary to complete an assessment and diagnosis, the CMHS psychiatrist will order laboratory tests and may refer for further medical assessment.

Complete Mental Health Assessment
Referral for services can be initiated at the time of the Intake Screening; presence of active prescriptions at Intake for psychotropic medication; anytime there is a mental health crisis, including suicidal threats and behavior; or, upon assignment to a special needs status in accordance with NCCHC Standards.  Inmates are encouraged to request services themselves, but may be referred by correctional, medical or any other staff when in need and unable or unwilling to do so.

All inmates who request or are referred for services are assessed by a Mental Health Professional, and an “Initial Treatment Plan” is completed.  This Initial Treatment Plan gathers enough detailed information to formulate a diagnostic impression, initiate immediate intervention as necessary, plan for follow-up as needed and make referral to a Psychiatrist or mid-level provider for a Comprehensive Mental Health Assessment when indicated.

The initial mental health assessment provides an initial baseline of information for further treatment planning by making inquiry into various areas including, but not limited to:

• Current suicidal ideation, history of suicidal, and/or self mutilating behavior
  
  
• Current and historical use of psychotropic medications
  
  
• Current mental status
  
  
• History of previous inpatient and outpatient mental health treatment
  
  
• Existence of vegetative signs of depression and/or active psychosis
  
  
• Drug and alcohol history
  
  
• History of violence or acting-out behaviors
  
  
• Educational history, including special placements
  
  
• History of medical conditions that may contribute to psychiatric symptoms (i.e., head injury, seizures, etc.)

The initial mental health assessment includes the identification of "special needs" inmates based upon chronic mental illness or developmental disability.  Any conditions identified in the initial mental health assessment that may appear to have an organic basis or may be influenced by medical factors are referred to medical staff for further assessment.

return to top