Standard Operating Procedure (SOP) for Mental Health

Assessment Report
I. IMC mission excerpts:
International Medical Corps’ mission is to improve the quality of life through health and mental
health interventions and related activities that build local capacity in underserved communities
worldwide. By offering training and healthcare to local populations and medical assistance to
people at highest risk, and with the flexibility to respond rapidly to emergency situations,
International Medical Corps rehabilitates devastated health care systems and helps bring them
back to self-reliance.
Today, International Medical Corps helps Lebanon handle the needs of the thousands of persons
including Syrians, Iraqis, Palestinians etc. who sought refuge here as well as members of the
vulnerable host communities. We provide primary health care, mental health, and psychosocial
services to both refugees and the local host population.

II. Purpose:
This Standard Operating Procedure (SOP) serves as a comprehensive guide detailing the
procedures and protocols employed by IMC for the management of mental health assessment
reports. It is important to emphasize that IMC possesses the discretion to either accept or decline
the provision of a mental health report. It underscores that IMC's decision to provide or not
provide a mental health report is based upon various factors. This document outlines the steps
and considerations involved in IMC's decision-making process when dealing with mental health
assessment reports, ensuring transparency and clarity in the approach.

III. Scope:
IMC recognizes the importance of mental health assessments and reports in the resettlement
process among other processes but emphasizes that it is not mandatory for every client or upon
every request. The decision to proceed with the provision of a mental health report is made on a
case-by-case basis, considering the client's needs, preferences, and best interest.
Furthermore, IMC has established a structured process to ensure the highest quality of care for
its clients. Requests for mental health reports require engagement with our case management
services for a continuous period of three months before they become eligible. This waiting period
serves to provide comprehensive and personalized support to clients, allowing them to build trust
and rapport with our MHPSS services, and allows the team to build a better understanding of the
overall case and being able to provide accurate information.

IV. Procedure:

1) Upon receiving a request for a mental health report, the designated case manager will initiate
a formal documentation process. This documentation helps ensure that all requests are
properly recorded and tracked for further review.

2) The case manager will then undertake a thorough review of the request. This review process
is conducted in close collaboration with the IMC mental health specialists. The primary
objective is to evaluate whether it is appropriate to proceed with the issuance of a mental
health report based on the specific circumstances of the individual and their needs.

3) During this assessment phase, several factors are taken into consideration. These factors
involve the person of concern's individual history, and any guidance provided by mental health
professionals who have been involved in the care plan. This holistic assessment ensures that
the decision regarding the mental health report aligns with the individual’s overall well-being
and treatment plan.

4) Should IMC accept the request, the relevant staff members including case managers,
psychotherapists, and psychiatrists (when applicable) will develop a comprehensive
assessment report following the designated template provided in Annex 1. To note that all
information provided in the report could be subject to change following the reporting period.

5) Should the MHPSS case management team decide not to approve the request, the requesting
party will receive notification explaining the rationale. However, upon approval, a memo from
international medical corps management team will be shared with the requesting party.

6) The Case management team will obtain written consent (template provided in Annex 2) from
the client prior to sharing the report with the third party; the original copy of the consent is to
be kept in the client’s file.

V. Review and Revision:

This SOP will be reviewed annually or as needed to ensure its effectiveness and relevance. Any
necessary revisions will be made in consultation with relevant stakeholders.
Annex 1:

Mental Health Assessment Report

Full Name Date of Referral to IMC

D.O.B PHCC & Area

Nationality Received Services:

☐Lebanese ☐Case Management
☐Syrian ☐Psychotherapist
☐Iraqi ☐Psychiatrist
Other: ………………………….
UNHCR ID Diagnosis

Case Manager Feedback (e.g., 1st session date, number of provided sessions, chief complaint
and main symptoms, care plan objectives and goals, important notes/observations etc.)

Psychotherapist Feedback (e.g., 1st session date, number of provided sessions, main
interventions, important notes/observations etc.)

Psychiatrist/mhGAP Feedback (e.g., 1st session date, number of provided sessions,

medications, important notes/observations etc.)
 Harm and Risk Factors (e.g., protection issues, suicidal thoughts/attempts, other risk factors
i.e. By the time this report was provided the client was not showing any suicidal
thoughts/ideation and thoughts of harming others.)

Prognosis and Recommendations (recommended to continue treatment, discharged, referrals

etc.)

All information mentioned in this report is subject to change following the reporting period.

Consent for sharing this information with a third party was obtained from the client and signature was received.

Date of report: __________________________________________

Team Signature (Please write the full name, position, and signature):

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Annex 2:

Information sharing consent form.

I (full name), __________________________________ the undersigned, acknowledge and agree that my

information could be shared with a third party for the purpose of obtaining a mental health report.

This consent form serves as evidence that I have reviewed and given my approval for the content of the
mental health report in question.

It is important to note that sharing your information is at your discretion, and you have the right to
withhold any of your personal details. Importantly, choosing not to share your information will not affect
the services you currently receive from IMC or any future services.

Accept ☐ Do not Accept ☐

‫ أقر وأوافق عىل إمكانية مشاركة معلومات مع‬،‫ __________________________________ الموقع أدناه‬، (‫أنا )االسم الكامل‬
‫طرف ثالث بغرض الحصول عىل تقرير الصحة النفسية‬

‫يعد نموذج الموافقة هذا بمثابة دليل عىل أنن قمت بمراجعة وموافقت عل محتوى تقرير الصحة النفسية‬
ً
‫ أن‬،‫ واألهم من ذلك‬.‫ ولديك الحق ف حجب أي من بياناتك الشخصية‬،‫ومن المهم مالحظة أن مشاركة معلوماتك تكون وفقا لتقديرك‬
ً ‫اختيار عدم مشاركة معلوماتك لن يؤثر عىل الخدمات الن تتلقاها‬
‫حاليا من الهيئة الطبية الدولية أو أي خدمات مستقبلية‬

☐ ‫ال أوافق‬ ☐ ‫أوافق‬

Client/ Caregiver Signature: _________________________

‫التوقيع‬

Date: _____________________________
‫التاري خ‬