PerformCareNJ Evaluation

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Evaluation for Counseling Services
A representative from Jersey Innovative Services contacted you via phone to complete an evaluation for counseling services. You were instructed to go to this page to give consent for the evaluation to begin. Your signature on this consent form is valid for this approved evaluation only today. If you have entered onto this site by mistake, leave this page empty. If you are interested in an evaluation for counseling services, call PerformCareNJ (877) 652-7624.

JERSEY INNOVATIVE SERVICES
Needs Assessment consent

Needs Assessment services for Youth (First name Last name)(required)

I hereby give my consent for this youth to be evaluated for services through NJ Children’s System of Care and PerformCareNJ on this day (First name Last name)(required)

As part of the Needs Assessment, Jersey Innovative Services is required to contact individuals/agencies outside of your home. I give permission for Jersey Innovative Services to contact these individuals/agencies below: Primary Care Physician (name/phone number)(required)

Clinician/Psychologist/Psychiatrist (name/phone number *if applicable)(required)

Hospital (name/phone number *if none, type none)(required)

Youth's school (school/phone number), add Child Study Team/Special Education representative in known (First name, Last name)(required)

Relative/Friend/Neighbor (name/relationship to them/phone number *if applicable)(required)

DCPP case worker (formally DYFS) type (name/number *if applicable)(required)

Youth's street address and town(required)

Final consent for evaluation here:(required)

Print your name (First name Last name) *consent is valid until one year from today(required)

Your personal email address(required)

Assessor name (person who sent you this form link)(required)

Press submit- Information sent confidentially.
Consent is valid (until one year from today)

Protection of your information
Privacy Practices: The HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule − requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without client authorization. (www.HHS.gov).

Protected Health Information (PHI) − protection applies to information collected from the individual or received by other team members agreed participants (www.PerformCareNJ.org). Jersey Innovative Services follows Federal, 42 CFR Part 2, State and HIPAA regulations to protect your confidentiality and asks permission to release information on you or your family.

Limits to Privacy: Federal law authorizes disclosure of information when there is: harm to self, harm to another or harm from someone. It is our obligation to protect you and others around you.

All assessments available in languages: Axomiya, Arabic, North African, American Sign Language (ASL), Balochi, Bangla, Brazilian Portuguese, Bulgarian, Cambodian, Cantonese, Chinese, Creole, Dari, Dogri, Egyptian, Farsi, French, French-Canadian, German, Greek, Gujarati, Haitian, Hausa, Hindi, Kashmiri, Kannada, Konkani, Korean, Indian Continent, Indonesian, Italian, Japanese, Laotian, Liberian, Levantine, Maithili, Malayalam, Mandarin, Manipuri, Marathi, Nepoli, Nuristani, Odia, Palestinian, Pashai, Pashto, Pidgin English, Portuguese, Punjabi, Romanian, Russian, Sanskirt, Serbian, Sidhi, Spanish, Tagalog, Tamil, Telugu, Thai, Twa, Turkish, Turmeni, Urdu, Uzbeki

Contact: Info@JerseyInnovative.com

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