background shadows

NJ DCF Logo with reverse copy


New Jersey Department of Children and Families Policy Manual




Child Protection and Permanency















CP&P Form 25-70, CP&P Referral Summary for Out-of-Home Treatment


Click here to view or print CP&P Form 25-70.




The CP&P Worker completes CP&P Form 25-70 when seeking an out-of-home treatment placement, which includes the following:

      Treatment Home;

      Group Home;

      Residential Facility;

      Specialty Bed; and

      Psychiatric Community Home.

When making a referral through PerformCare, upon completion of the CP&P Form 25-70, the CP&P Worker telephones PerformCare to conduct a Telephonic Review for out-of-home treatment placement. The completed CP&P Form 25-70 is an important tool used to facilitate the review process.

The PerformCare representative assigns an "intensity of service" (IOS) level. The CP&P Worker sends the CP&P Form 25-70 and the "referral packet" to appropriate providers at the IOS level determined by PerformCare. The "referral packet" may also be sent to providers at a lower IOS level than given by PerformCare. Do not send packets to providers at higher levels than given by PerformCare.

The "referral packet" includes, as applicable, all recent:

      Clinical evaluations;

      Child Study Team (CST) reports;

      Individual Education Plan (IEP) reports; and;

      Relevant Court Orders.

Note: If a youth is placed with a provider at a lower IOS level than determined by PerformCare, it is expected that the provider is able to provide for the needs of the youth within their current clinical milieu, i.e., without additional fiscal or staffing support to augment the program for the youth being placed for treatment.

When making a referral to a CP&P contracted treatment provider (one not under the jurisdiction of the DCF Children's System of Care, the CP&P Worker mails the completed CP&P Form 25-70 and the "referral packet," as described above, to the prospective treatment provider.




CP&P does not complete CP&P Form 25-70 if DCF Children's System of Care Case Management (i.e., CMO/UCM/YCM) is working with the youth, or if the youth is currently in out-of-home treatment. In these situations, DCF Children's System of Care Case Management or the current out-of-home treatment provider is responsible for making the request.




      Copy and paste the form onto your desktop.

      Rename and save the form.

      Enter in the responses to sections 1 through 10 of the form using the most recent clinical evaluations available. It is important that the form be as accurate and as descriptive as possible.

      Ensure that Section 11 is signed.

      When looking for a behavioral health out-of-home treatment placement, upon completion of CP&P Form 25-70, the CP&P Worker calls PerformCare to conduct a Telephonic Review for out-of-home treatment placement. The completed CP&P Form 25-70 is an important tool used to facilitate the review process.

Note: When seeking a "CP&P contracted" out-of-home treatment placement, i.e., not one under the jurisdiction of DCF Children's System of Care, the telephonic review is not necessary.


The "Telephonic Review" is a telephone discussion triage between the CP&P Worker and a Care Coordinator from PerformCare regarding a youth's current behavioral health treatment needs.

Initial questions asked by the Care Coordinator include:

      Youth's current legal status.

-       CP&P must have the legal authority to facilitate the out-of-home placement referral, i.e., a Court Order or signed Residential Placement Agreement (CP&P Form 25-59).

Note: If the youth is age 18 or older, the Residential Placement Agreement (CP&P Form 25-59), signed by the youth, or verbal consent of the youth (given over the phone by the youth) to PerformCare, is required.

      The name of the CP&P Supervisor who approved the out-of-home treatment referral request.

The Care Coordinator will then ask for information regarding the youth's behaviors, treatment history, etc. The following evaluations, when applicable, are required to complete the Telephonic Review:

1.    Bio-Psycho-Social or Psychological Evaluations completed within the past 12 months (if the last evaluation was completed longer than 6 months ago, CP&P will receive an Intensity of Service (ISO) level determination, but will be asked to provide an updated report from the youth's therapist).  If no evaluations have been completed, or the current evaluation is more that one year old, PerformCare can set up a Bio-Psycho-Social Evaluation.

2.    Psychiatric Evaluation (required if the youth is currently prescribed any psychotropic medication).

3.    Psychiatric Evaluation or Psychiatric Discharge document (if the youth has been hospitalized for mental/behavioral health reasons within the past 45 days).

4.    Specialized Evaluations (if applicable):

a.    Fire Setting Evaluation with Risk Level;

b.    Psychosexual Evaluation with Risk Level;

c.    Substance Abuse Evaluation.

After all the information is discussed, the Care Coordinator will make a determination regarding the Intensity of Service (IOS) for the out-of-home treatment needed and will then post a referral to "Youth Link" for out-of-home providers to review for possible admission. The determination made by the Care Coordinator is based on the clinical needs of the youth and the DCF Children's System of Care clinical criteria.

PerformCare will send the CP&P Worker a follow-up email with the IOS Determination and a list of potential out-of-home treatment providers. A provider with a lower IOS may admit the youth but they must clearly define how they will support the treatment needs of the youth.

PerformCare will provide instructions on how to facilitate the placement through the Special Residential Treatment Unit (SRTU), if the IOS is for a specialty treatment (SPEC), a Psychiatric Community Home (PCH), or for a pregnant youth.

If a youth remains on Youth Link for more than 30 days, the CP&P Worker sends the referral packet to the SRTU for consultation.



Original          -     

Child's case record

Copy             - 

Treatment Provider (when making referral to a CP&P contracted provider, or upon request when making a referral to a provider under the jurisdiction of PerformCare).