Integrated Health

Psychiatric Advance Directive (PAD) [English] [Spanish]
Instructions for completing a PAD [English] [Spanish]

Application for Involuntary Commitment (posted January 2013)
Clinical/Screening Certificate for Involuntary Commitment for Mentally Ill Adults (September 2014)
Temporary Order for Involuntary Commitment to Treatment of an Adult (Outpatient Treatment)
Temporary Order for Involuntary Commitment to Treatment of an Adult (Inpatient Treatment)

Individualized Rehabilitation Plan

Community Support Services Enrollment Form
The enrollment form must be submitted to the Interim Management Entity (IME) for all CSS consumers.
Community Support Services Enrollment Form

Community Support Services Fax Cover Sheet
The fax cover sheet must be used when providing a submission to the Interim Management Entity (IME). Each submission to the IME must be separate and accompanied by a separate fax coversheet.
Community Support Services Fax to IME Sheet

Preliminary and Comprehensive Rehabilitation Needs Assessment (PRNA & CRNA)
The rehabilitation needs assessment is a template that provider agencies may use to gather all information required to determine a consumer’s individual strengths, preferences, needs, abilities, psychiatric symptoms, medical history, and functional limitations.
PRNA and CRNA Template

Individualized Rehabilitation Plan (PIRP & IRP) Template
The individualized rehabilitation plan template, whether for PIRP or IRP, is a DMHAS form that all CSS providers must use to outline a consumer’s goal(s).
CSS Blank IRP Form

Individual Rehabilitation Plan Modification Form
This form must be submitted to the IME when modifications are made to the IRP.
CSS IRP Modification Form
CSS IRP Modification Form - Changing Funding Source

Individualized Rehabilitation Plan (IRP) Sample #1
This completed IRP provides an example of how to outline a consumer’s chosen goals, objectives, and provider interventions.
Final Sample IRP for Webinar

Detainer Form

ICMS Forms [Community] [Interim]
ICMS Termination Request

Request for Police Transport and Supervision (Outpatient Treatment)
Request for Police Transport and Supervision (Screening Outreach)

Categorical Determination Psychiatric Evaluation
Level II Psychiatric Evaluation Form
Level II Psychiatric Evaluation Webinar Training
Resident Review Form

Clinical/Screening Certificate for Involuntary Commitment for Mentally Ill Adults
Screening Document for Adults

N.J. DMHAS Letter to Providers
N.J. Department of Health Letter to Healthcare Facility Providers
Instructions
Transfer Form
Inpatient Interfacility Transfer Form

You can e-mail your USTF data to: dmhs.ustf@doh.nj.gov

Acceptance/Termination
Emergency/Screening
Incoming/Outgoing Client Transfers
Manual
Project Code Listing
Service Area Listing

Administrative Order 2:05
Community UIRMS Contacts 
Community Mental Health (MH) Provider UIRMS Training Powerpoint
Substance Use Disorder (SUD) Provider UIRMS Training Powerpoint
Community Closure Addendum for MH and SUD Programs
Category List for MH and SUD Programs

Reportable Incident Categories by Program Type for MH and SUD Treatment Providers

Process Flow Chart for MH and SUD Programs

Initial Incident Report Form for MH and SUD Programs | Paper Version | Electronic Version | Protocol for Initial Incident Report Form

Follow-up Report Form for MH and SUD Programs | Paper Version | Electronic Version | Protocol for Follow-up Report Form

Appendix 1 for MH and SUD Programs |Paper Version | Electronic Version

Appendix 2 - Substance Use Questionnaire for MH and SUD Programs | Paper Version | Electronic Version
Appendix 2a - Overdose Questionnaire for MH and SUD Programs | Paper Version | Electronic Version

Appendix 3 - Sudden and Unexpected Death Questionnaire for MH and SUD Programs | Paper Version | Electronic Version

Appendix 4 - Suicide or Suicide Attempt Questionnaire for MH and SUD Programs |Paper Version | Electronic Version

Archives

Community Mental Health (MH) Provider UIRMS Training Powerpoint

Substance Use Disorder (SUD) Provider UIRMS Training Powerpoint

Agency Referral and Response Form
Metabolic Syndrome Tracking Form
Psychotropic Medication Emergency Certification Form