COMPLETED BY PRIMARY THERAPIST/MENTAL HEALTH EMPLOYEE ...

REENTRY COMMUNITY SERVICES PROGRAM REFERRAL

Name: Current offense: Last RCSP referral date (General Info OMNI):

DOC number:

Earned release date: Max Ex date:

Referral initiated by:

Date of birth:

Sex offender risk category:

Sex offender level:

COMPLETED BY PRIMARY THERAPIST/MENTAL HEALTH EMPLOYEE/CONTRACT STAFF

Current mental health diagnosis:

S Code: U Code: R Code: H Code:

Current

Highest Date of highest

Yes No History of psychiatric hospitalizations? Where:

Yes No History of community mental health treatment? Where:

Employee/contract staff

Position/title

Facility

COMPLETED BY CASE MANAGER

Risk Level Classification: High Violent (HV) High Violent Property Drug (HVPD)

High Property (HP) Moderate (M)

Date

High Drug (HD) Low (L)

Yes No History of substance use disorder or dependence? Yes No History of felony violent or serious violent conviction? Yes No Sex offender Level III? Yes No Use of a weapon during an offense? Yes No History of violent serious infractions?

Assigned supervision:

Case manager

Position/title

Facility

Date

DOC 14-030 (08/20/21)

Page 1 of 2

DOC 630.590 LEGAL: Mental Health

CRITERIA FOR RCSP DESIGNATION

Mental disorder criteria:

Mental disorder means any organic, mental, or emotional impairment which has substantial adverse effects on an individual's cognitive or volitional functions per RCW 71.05.020.

Substantial adverse effects will be supported by identification of significant functional impairment, such as an inability to complete activities of daily living without support.

The RCSP Review Committee will take into consideration the clinical history of each candidate being reviewed. The following factors will be considered, at a minimum:

Substantiation of the qualifying diagnosis through documented observations from mental health providers.

Corroboration of symptom presentation across time and setting or recent evidence of an acute episode.

Dangerousness criteria:

Dangerousness includes danger to self and/or others.

The following factors will be considered, at a minimum: Risk Level Classification (RLC) Substance use disorder/dependence history Current offense and criminal history Sex offender Level III Sex offender risk category History of violent/serious violent infractions (i.e., Infraction Group Number and seriousness) Danger to self, including:

o Substantiated history of suicide attempt(s)

o Significant self-injury behavior in the last 2 years

State law and/or federal regulations prohibit disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.

Distribution: ORIGINAL - Health Record

COPY - RCSP

DOC 14-030 (08/20/21)

Page 2 of 2

DOC 630.590 LEGAL: Mental Health

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