In the bustling metropolis of Los Angeles County, the Department of Public Social Services orchestrates a pivotal program known as General Relief Opportunities for Work (GROW), designed to support individuals grappling with mental health challenges on their path to employment. Central to this initiative is the ABP 1466 form, a document that bridges the gap between participants and clinical assessment providers. On its first page, the form outlines an appointment notice for a mental health assessment, emphasizing the critical nature of attendance and providing essential details such as the date, time, location, and contacts for any necessary communication. The form thoughtfully requests participant information, including personal and confidential contacts, to ensure tailored and sensitive handling. The second page delves into the outcomes of the clinical assessment, detailing whether the participant attended, the results of the assessment, and the subsequent steps recommended, whether that involves further assessments, treatment agreement, or disagreement. By completing this form, participants consent to sharing the outcome with the Department of Public Social Services, marking a significant step in their journey towards mental well-being and employment readiness. This form encapsulates Los Angeles County's commitment to supporting its residents through structured, compassionate, and personalized care.
| Question | Answer |
|---|---|
| Form Name | Form Abp 1466 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dpss grow abp 1467, DPSS, REFERRAL, ABP |
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COUNTY OF LOS ANGELES |
DEPARTMENT OF PUBLIC SOCIAL SERVICES |
GENERAL RELIEF OPPORTUNITIES FOR WORK
CLINICAL ASSESSMENT PROVIDER REFERRAL AND
SERVICE RESULTS REPORT
GROW SITE:
ADDRESS:
DATE:
CASE NAME:
CASE NUMBER:
IMPORTANT APPOINTMENT NOTICE
The following appointment has been scheduled for you
to attend a clinical assessment for mental health.
Date of Appointment:
Time:
Location:________________________________
Address:_________________________________
Phone
Number:________________________________
IT IS IMPORTANT FOR YOU TO KEEP THIS APPOINTMENT
***TAKE THIS NOTICE WITH YOU***
If for any reason you cannot keep this appointment or have a problem, please contact me immediately.
GROW CASE MANAGER: |
FILE NUMBER: |
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PHONE NUMBER: |
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SECTION A - PARTICIPANT INFORMATION |
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PARTICIPANT NAME: |
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CASE NUMBER: |
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RESIDENCE ADDRESS: |
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MAILING ADDRESS (CONFIDENTIAL): |
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PRIMARY LANGUAGE: |
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BIRTH DATE: |
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GENDER: |
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TELEPHONE NUMBER (CONFIDENTIAL): |
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SOCIAL SECURITY NUMBER: |
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ABP 1466 Revised 11/08 |
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Page 2 of 2
SERVICE RESULTS
SECTION B - COMPLETED BY CLINICAL ASSESSOR (Please complete and return to GROW Case Manager
within five business days.)
RESULTS OF CLINICAL ASSESSMENT FOR _______________________________________________________:
PARTICIPANT NAME
‘Participant did not appear/assessment not completed.
‘Participant completed the assessment, but does not need a referral for treatment.
‘Participant completed assessment and needs a referral, but does not agree to treatment for mental health.
‘Participant completed assessment and agrees to recommended treatment for mental health. Please see below for appointment details:
Date of appointment: ______________ Location: ___________________________
Time: ___________________________ Address: ___________________________
Telephone Number: ( |
)__________ |
‘Participant does not agree with completed assessment, requests third party assessment.
RECOMMENDED THIRD PARTY ASSESSMENT PROVIDER(S): include name, address, phone
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
ASSESSOR SIGNATURE:
DATE:
SECTION C - COMPLETED BY GROW PARTICIPANT
I authorize the release of information to DPSS regarding the results of my assessment and possible need for treatment services.
‘Yes, I agree to the service plan developed and agree to attend treatment.
‘No, I do not agree to the service plan and will not attend treatment.
_____________________________________ |
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GROW Participant Signature |
Date |
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ABP 1466 revised 11/08 |
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