background shadows

NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

8-22-2007

Subchapter:

1

Forms

Issuance:

11.46

CP&P Form 11-46, Adult Substance Use Disorder Assessment Referral Form

 

 

Click here to view the CP&P Form 11-46, Adult Substance Use Disorder Assessment Referral Form.

 

WHEN TO USE IT

 

This form is used to refer a CP&P adult client, parent or caregiver of a CP&P-supervised child, for a complete substance use assessment to determine:

 

·         If the client has a substance use problem

·         The level of severity of the substance use

·         The level of care required to appropriately treat the substance use problem

 

HOW TO USE IT

 

·         Access it through the NJ Spirit Desktop > Create Case Work > Forms.

·         Only complete this template outside of the NJ Spirit application as part of a contingency plan when the application is unavailable. However, you are still required to create the form in NJ Spirit when the application becomes available.

·         Part I of this form is completed electronically by the Worker. Part II is completed electronically by the Worker in consultation with his or her Supervisor. The form is then printed and manually approved by the Worker and Supervisor.

·         The Supervisor forwards the form to the Gatekeeper/Liaison or Resource Development Specialist in the Local Office who reviews and adjusts the Priority Level, if needed, and completes Part III. He or she then signs the printed copy of the form and forwards it to the in-house Substance Use Disorder Specialist/CADC, the community-based substance use assessor or substance use treatment provider.

·         The CADC, community-based assessor, or treatment provider signs the form upon receipt, processes the request for services, and sends a signed copy to the CP&P Worker.

 

TIPS FOR COMPLETING THE FORM

 

The Substance Use Disorder Specialist/CADC or the Resource Development Specialist located in your Local Office and your Supervisor can help you complete this form. Failure to provide sufficient information delays the assessment.

 

In Part I:

o   In the "Date Referred" field, enter the date the form was manually approved and sent to the in-house Substance Use Disorder Specialist/CADC, the community-based substance use or assessor or substance use treatment provider. (Required)

o   "In-Home/Out-of-Home" check boxes refer to the child's placement status at the time of this referral.

o   In the "Types of Substance(s).Duration of Use" text field, list the amount of time (i.e., months, years) the referred person says he or she has been using the substances. If duration of use differs, list each substance separately. Use the National Institute on Drug Abuse (NIDA) chart which is part of this form to identify substances.

o   The questions regarding out-of-home placement, the ASFA discussion and potential date of TPR must be answered or the referral will be returned for completion. In your responses, enter the day, month, and year. ASFA guidelines and state regulations require the initiation of termination of parental rights (TPR) proceedings for parents of children who have been in out-of-home placement for 15 of the last 22 months with specific exceptions. If no child is in placement, enter "Not Applicable" for the ASFA and TPR discussions. See N.J.S.A. 30:4C-15(f) and CP&P-supervised child, for a complete substance use or abuse assessment to determine:

o

o-     If the client has a substance use or problem

o-     The level of severity of the substance use or problem

o-     The level of care required to appropriately treat the substance use or problem

o

oHOW TO USE IT

o

oAccess it through the NJ Spirit Desktop > Create Case Work > Forms.

oOnly complete this template outside of the NJ Spirit application as part of a contingency plan when the application is unavailable. However, you are still required to create the form in NJ Spirit when the application becomes available.

o

Part I of this form is completed electronically by the Worker. Part II is completed electronically by the Worker in consultation with his or her Supervisor. The form is then printed and manually approved by the Worker and Supervisor.

The Supervisor forwards the form to the Gatekeeper/Liaison or Resource Development Specialist in the Local Office who reviews and adjusts the Priority Level, if needed, and completes Part III. He or she then signs the printed copy of the form and forwards it to the in-house Substance Use Disorder Specialist/CADC, the community-based substance use or assessor or substance use treatment provider.

The CADC, community-based assessor, or treatment provider signs the form upon receipt, processes the request for services, and sends a signed copy to the CP&P Worker.

TIPS FOR COMPLETING THE FORM

The Substance Use Disorder Specialist/CADC or the Resource Development Specialist located in your Local Office and your Supervisor can help you complete this form. Failure to provide sufficient information delays the assessment.

In Part I:

In the "Date Referred" field, enter the date the form was manually approved and sent to the in-house Substance Use Disorder Specialist/CADC, the community-based substance use or assessor or substance use treatment provider. (Required)

"In-Home/Out-of-Home" check boxes refer to the child's placement status at the time of this referral.

In the "Types of Substance(s).Duration of Use" text field, list the amount of time (i.e., months, years) the referred person says he or she has been using the substances. If duration of use differs, list each substance separately. Use the National Institute on Drug Abuse (NIDA) chart which is part of this form to identify substances.

The questions regarding out-of-home placement, the ASFA discussion and potential date of TPR must be answered or the referral will be returned for completion. In your responses, enter the day, month, and year. ASFA guidelines and state regulations require the initiation of termination of parental rights (TPR) proceedings for parents of children who have been in out-of-home placement for 15 of the last 22 months with specific exceptions. If no child is in placement, enter "Not Applicable" for the ASFA and TPR discussions. See N.J.S.A. 30:4C-15(f) and CP&P-IV-C-1-500.

In Part II:

·         The "Priority Level for Referral" sets the time frames for assessment. Priority #1 is the most imperative.

·         Give a detailed explanation of each criterion used to determine Priority #1.

·         Medical evidence:  note if the report is from a hospital or doctor; report of a baby born addicted; drug overdose; accident or injury due to drug use or abuse, etc.

·         Admission:  enter the date the client admitted to chronically substances. Give details of the circumstances.

·         Statements to professional(s) from the child:  identify the professional (e.g., counselor, teacher, etc.).

·         Personal observation:  give details of the observations which lead you (the Worker) to believe the parent or caregiver is using substance(s).

 

·         Other:  give the name of any other source (agency or person) and relationship to user/abuser (local police, neighbor, etc.), if known, and any relevant details.

 

·         For Priority #2, use the SDM tools to help determine the risk of harm and to guide decision-making about reunification planning. See CP&P-III-B-6-600 for policy and forms.

·         If the alleged substance use has a negative impact, but it does not rise to the level of child abuse or neglect, and the parent is willing to accept services voluntarily or the projected date of termination of parental rights is not within 6 months, select Priority #3 and indicate the type of case.

·         List any reports attached (e.g., past substance use treatment report, psychological or psychiatric report).

Part III is completed by the Gatekeeper/Liaison or Resource Development Specialist in the Local Office.

 

In Part IV, "Signatures," print the form and approve it with manual signatures.

 

DISTRIBUTION

 

Original                                  In-house Substance Use Disorder Specialist/CADC or community-based substance use or assessment or treatment provider (with signatures)

 

Copy                           -           CP&P case record

 

Electronic copy         -           NJ SPIRIT Electronic Case Record,

                                                                        Forms icon (without signatures)