General Relief Policy - Department of Public Social Services

committing suicide.
• Danger to or has a history of hurting self (e.g.,
signs of cuts or burns), or other people, or
destroying property.
• Has undergone mental health treatment in last
five years.
GR 41-103 – NSA Case
Identification
Is there a form to help EWs decide whether a
participant should be referred for a mental
health assessment with Department of Mental
Health (DMH) staff?
Yes, the ABP 4029, Mental Health Screening Form,
leads the EW through a series of questions and
assigns a point value for each question.
Participants who score seven or more are referred
for an assessment by DMH staff.
• The EW asks the questions on the form and
records the participant’s answer by entering a
zero for “no” or the point value using the number
(1, 3, 4, or 7 points) indicated by the “yes.” Then
the total number of points is entered on line 11.
• A score of seven or more triggers a referral to
DMH. Remember to attach this form to the
PA 2012.
• Scores less than seven points are generally not
referred to DMH.
• However, a participant who requests a referral
can be referred, even if s/he scores less than
seven points.
The EW may also refer participants who score less
than seven points due to observable characteristics
or another reason. The reason for the referral is
written on the lines provided just below line 11 on
the form.
GR 41-103.1 – Case
Folder
How is a case folder identified for NSA
individuals?
To ensure that mentally disabled individuals are
easily recognized in order to receive the special
assistance they require, the following measures are
taken IMMEDIATELY upon identification as
potentially mentally disabled: