Looking for Other NJ Health Forms?

The forms on this page are related to the mental health and addiction services available through the Integrated Health division. Forms for other programs are available through those programs' respective websites or through the main forms page for the Department of Health. 

Health Department Forms

Integrated Health Forms


Advance Directives (Psychiatric)

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


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Commitment
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Community Support Services

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


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Detainer
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Integrated Case Management Services (ICMS)
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Police Transport and Supervision
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Pre-Admission Screening Resident Review (PASRR)
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Screening
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State Psychiatric Interfacility Transfers
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Unified Services Transaction Forms (USTF)
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Unusual Incident Reporting Forms

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


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Miscellaneous Forms
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Last Reviewed: 11/13/2017