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