referral for mental health services - Department of Public Social ...

COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
REFERRAL FOR MENTAL HEALTH SERVICES
SECTION 1 – IDENTIFICATION (To be completed by DPSS Staff)
CASE NAME – First Name, Last Name District Name District Number
Client’s Case Number (if different) EW/GCM Name EW/GCM File Number
Client’s Name
EW/GCMs Telephone Number
Client’s Address (vendor hotel name if applicable) Client’s Social Security Number Client’s Date of Birth
Client’s Telephone Number (hotel number if applicable)
General Relief Case Status:
□ Pending □ Approved □ Unknown
Previously referred for Mental Health Services:
□ Yes □ No □ Unknown
Date
Emergency assistance issued for: □ Housing □ GR □ CalFresh □ Transportation □ Mental Health Assessment
Client has return appointment with EW/GCM on date __________________________________ at (time) __________________
SECTION 2 – REASON FOR REFERRAL (To be completed by DPSS Staff)
Check all that apply and explain briefly:
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Client’s behavior __________________________________________________________________________________________
Medical/psychiatric history __________________________________________________________________________________
Other (specify) ____________________________________________________________________________________________
SECTION 3 – SERVICES REQUESTED (To be completed by DPSS Staff)
Check all that apply and explain if necessary:
□ Mental Health Disability Assessment □ NSA Screening □ Referral to SSI Advocate
□ Volunteered to go to GROW □ Yes □ No □ Assist with GR Procedures (explain) □ Other Services (explain)
Explain: ____________________________________________________________________________________________________
SECTION 4 – SERVICES PROVIDED BY DMH/APS/DPSS Social Workers (To be completed by DMH/APS/DPSS Social Workers)
Check all that apply:
□ Mental Health Disability Assessment □ Referred Mental Health Services Name of hospital, clinic, other provider
□ NSA Screening (APS/DPSS Social Workers) □ Hospitalization (Treating facility: current or previous)
□ SSI Determination □ Outpatient Treatment ___________________________________
___________________________________
SSI Eligible? □ Yes □ No □ Counseling ___________________________________
___________________________________
76R 251M PA 2012 (REV. 01/13)
(Two-Sided Form)

COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
□ Assisted with GR Procedures:
□ Application forms □ Eligibility Documentation
□ Emergency Aid □ Work Exemption □ Other (explain) ____________________
□ Transported to: ___________________________________________________________________________________________
□ Limited or no services provided because:
□ Client refused services □ Not needed (explain) □ Other reason (explain)
Explain: ____________________________________________________________________________________________________
SECTION 5 – DISPOSITION BY DMH/APS/ DPSS Social Workers STAFF (To be completed by DMH/APS Staff)
Check all that apply and describe briefly:
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Client is not NSA
□ Client is permanently NSA (12 months or more).......................................................Should patient apply for SSI/SSP? Yes No
□ Client is temporarily NSA. Will be re-evaluated on _________ (less than 12 mos.) Should patient apply for SSI/SSP? Yes No
□ Participant is willing to work. □ Yes □ No
Does the participant have any of the following problems?
□ Drug or Alcohol Abuse □ Developmentally Disabled □ Other Medical Problems (type) ___________________
Other Comments: ____________________________________________________________________________________________
___________________________________________________________________________________________________________
SECTION 6 – OBSERVABLE IMPAIRMENTS BY DMH STAFF (To be completed by DMH Staff)
Common Impairments which may impact the participant’s ability to work. Check all that apply:
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Lack of Motivation
Memory Problems
Difficulty Getting Along with others
Distrustful of others
Irritability/Restlessness
Easily Distracted
Talking To Self
Hearing and/or Seeing Things
DMH/APS/ DPSS SW STAFF Name: Telephone: Date:
76R 251M PA 2012 (REV. 01/13)
ORIGINAL