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I. Definitions and Legal Standards (State of New Jersey)

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Effective 9/30/2014 Clinical/Screening Certificate Page 1 of 15
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STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
Division of Mental Health and Addiction Services
CLINICAL/SCREENING CERTIFICATE FOR INVOLUNTARY COMMITMENT
OF MENTALLY ILL ADULTS
(Pursuant to N.J.S.A. 30:4-27.1, et seq. and N.J. Court Rule 4:74-7)
If additional space is needed to provide the information requested, additional documents may be
attached to this form.
I. Definitions and Legal Standards
New Jersey Court Rule 4:74 states in part that: “…the certificates shall state with particularity the
facts upon which the psychiatrist, physician, or mental health screener relies in concluding that (1)
the patient is mentally ill, (2) that mental illness causes the patient to be dangerous to self or others
or property as defined by N.J.S.A. 30:4-27.2h and .2i, (3) the patient is unwilling to accept
appropriate treatment voluntarily after it has been offered, (4) the patient needs outpatient treatment
or inpatient care at a short term care or psychiatric facility or special psychiatric hospital, and (5)
other less restrictive alternative services are not appropriate or available to meet the person’s
mental health care need.”
Chapter 4 of Title 30 of the New Jersey Statutes states in part that:
1. “Clinical Certificate” is completed by the psychiatrist or other physician who has examined the
person who is subject to commitment within three days of presenting the person for involuntary
commitment to treatment, and which states that the person is in need of involuntary
commitment to treatment. The form shall also state the specific facts upon which the
examining physician has based his conclusion and shall be certified in accordance with the
Rules of the Court. A clinical certificate may not be executed by a person who is being
screened. (N.J.S.A. 30:4-27.2b).
2. “Screening Certificate” means a clinical certificate executed by a psychiatrist or other
physician affiliated with a screening service. (N.J.S.A. 30:4-27.2y)
3. “Physician” means a person who is licensed to practice medicine in any of the United States or
its territories, or the District of Columbia. (N.J.S.A. 30:4-27.2t)
4. “Psychiatrist” means a physician who has completed the training requirements of the American
Board of Psychiatry and Neurology. (N.J.S.A. 30:4-27.2v)
5. “In need of involuntary commitment” or “in need of involuntary commitment to treatment”
means that an adult with mental illness, whose mental illness causes the person to be dangerous
to self or dangerous to others or property and who is unwilling to accept appropriate treatment
voluntarily after it has been offered, needs outpatient treatment or inpatient care at a short-term
care or psychiatric facility or special psychiatric hospital because other services are not
appropriate or available to meet the person’s mental health care needs. (N.J.S.A. 30:4-27.2m)
Effective 9/30/2014 Clinical/Screening Certificate Page 2 of 15
6. “Dangerous to self” means that by reason of mental illness the person has threatened or
attempted suicide or serious bodily harm, or has behaved in such a manner as to indicate that
the person is unable to satisfy his need or nourishment, essential medical care or shelter, so that
it is probable that substantial bodily injury, serious physical harm or death will result within
the reasonably foreseeable future; however, no person shall be deemed to be unable to satisfy
his need for nourishment, essential medical care or shelter if he is able to satisfy such needs
with the supervision and assistance of others who are willing and available. This determination
shall take into account a person’s history, recent behavior and any recent act, threat or serious
psychiatric deterioration. (N.J.S.A. 30:4-27.2h)
7. “Dangerous to others or property” means that by reason of mental illness there is a substantial
likelihood that the person will inflict serious bodily harm upon another person or cause serious
property damage within the reasonably foreseeable future. This determination shall take into
account a person’s history, recent behavior, and any recent act, threat, or serious psychiatric
deterioration. (N.J.S.A. 30:4-27.2i)
8. “Mental Illness” means a current, substantial disturbance of thought, mood, perception or
orientation which significantly impairs judgement, capacity to control behavior, or capacity to
recognize reality but does not include simple alcohol intoxication, transitory reaction to drug
ingestion, organic brain syndrome, or developmental disability unless it results in the severity
of impairment described herein. The term mental illness is not limited to "psychosis" or "active
psychosis," but shall include all conditions that result in the severity of impairment described
herein. (N.J.S.A. 30:4-27.2r)
9. "Outpatient treatment provider" means a community-based provider, designated as an
outpatient treatment provider pursuant to section 8 of P.L.1987, c.116 (C.30:4-27.8), that
provides or coordinates the provision of outpatient treatment to persons in need of involuntary
commitment to treatment. (N.J.S.A. 30:4-27.2ii)
10. "Plan of outpatient treatment" means a plan for recovery from mental illness approved by a
court pursuant to section 17 of P.L.2009, c.112 (C:30:4-27.15a) that is to be carried out in an
outpatient setting and is prepared by an outpatient treatment provider for a patient who has a
history of responding to treatment. The plan may include medication as a component of the
plan; however, medication shall not be involuntarily administered in an outpatient setting.
(N.J.S.A. 30:4-27.2jj)
11. "Reasonably foreseeable future" means a time frame that may be beyond the immediate or
imminent, but not longer than a time frame as to which reasonably certain judgments about a
person's likely behavior can be reached. (N.J.S.A. 30:4-27.2kk)
12. “Any person who is a relative by blood or marriage of the person being screened who executes
a clinical certificate, or any person who signs a clinical certificate for any purpose or motive
other than for purposes of care treatment, and confinement of a person in need of involuntary
commitment to treatment shall be guilty of a crime of the fourth degree.” (N.J.S.A. 30:4-
27.10e)
The statutes and Court Rule require each certifying psychiatrist or physician to determine whether
the patient is in need of involuntary commitment to inpatient treatment or involuntary commitment
to outpatient treatment (where available) by considering the screening document (in the case of a
Effective 9/30/2014 Clinical/Screening Certificate Page 3 of 15
screening commitment) and conducting a face-to-face examination of the patient, either in person
or, where permitted by the Division, through telepsychiatry.
II. Certification of Examination and Qualifications
A. I , M.D./D.O.of
(Street Address)
(City or Town) County State Medical License No. Issuing State
do hereby certify that I personally examined
(Name of Patient)
at on from am/pm to am/pm.
(Location) (Date) (Time of Examination)
I am a psychiatrist as defined in section I of this document.
I am a physician as defined in section I of this document.
B. I am not a relative by blood or marriage of the subject of this certificate and my purpose or
motive in executing this certificate is that care and treatment be afforded this individual.
C. If an interpreter assisted in this personal examination, the interpreter's name and title and the
patient's primary language are as follows:
(Name) (Title) (Language)
D. Check and complete one of the following options below. This document is being prepared as
a:
1. Screening Certificate pursuant to N.J.S.A. 30:4-27.5b completed by a psychiatrist
affiliated with a screening service (see N.J.S.A. 30:4-27.2y) unless the screening service’s
contract allows a physician to complete the certificate; (see N.J.S.A. 30:4-27.5b); and
I am a psychiatrist as defined in section 1 of this certificate.
I am a physician as defined in section I of this certificate who may complete this
certificate pursuant to a contract between the screening service and the Division of Mental
Health and Addiction Services.
Or
2. Clinical Certificate pursuant to N.J.S.A. 30:4-27.10a (must be the treatment team
psychiatrist of a patient at an inpatient facility or an outpatient treatment provider for whom
a screening certificate has also been completed);
or
Effective 9/30/2014 Clinical/Screening Certificate Page 4 of 15
3. Clinical Certificate pursuant to N.J.S.A. 30:4-27.10b (regarding an individual who
has not been referred by a screening service and whose commitment requires two clinical
certificates, at least one of which must be completed by a psychiatrist.
I am a psychiatrist as defined in section 1 of this certificate.
I am a physician as defined in section 1 of this certificate.
III. Telepsychiatry (if Telepsychiatry not used, skip to IV)
Telepsychiatry was the means by which the interview with the patient was conducted.
Complete each numbered provision below and initial each statement that applies.
1. The consumer was afforded the opportunity to have an in-person interview; or
The consumer elected a face-to-face evaluation but the evaluation was performed
by telepsychiatry because waiting for a psychiatrist was clinically contraindicated.
Briefly explain:
2. Telepsychiatry was not clinically contraindicated because:
3. I am on the staff of the screening service; or I am under contract with a
provider of telepsychiatry services.
4. I hold a full, unrestricted medical license in New Jersey.
5. I am capable of performing all the duties that an on-site psychiatrist can perform,
including prescribing medication, monitoring restraints and other related interventions
that require a physician’s orders or oversight.
6. I am available for discussion of the case with facility staff, and/or for interviewing
family members and others, as the case may require.
Effective 9/30/2014 Clinical/Screening Certificate Page 5 of 15
IV. Patient Identification and Information
1. Patient’s identifying data:
Social Security No. DOB:
Marital Status: Telephone No.
Driver’s License: State Issued:
Address:
Next of Kin (for County Adjuster court hearing notification purposes only):
(Name)
Next of kin contact information:
(Address) (Phone No.)
Education (Highest Grade Completed): Employment or Occupation:
2. Psychiatric Advance Directive:
The patient does not have a Psychiatric Advance Directive (PAD) (go to 3.);
It could not be determined after a reasonable inquiry whether the patient has a PAD
(go to 3.);
The patient claims to have a PAD, but after a reasonable search it has not been
found (go to 3); or
The patient has a PAD which is appended hereto.
The PAD names to act as a
Mental Health Care Representative.
The PAD does not name a Mental Health Care Representative.
3. Patient’s presenting conditions:
a. Medical Conditions:
Treating Physician:
Medications:
Effective 9/30/2014 Clinical/Screening Certificate Page 6 of 15
Source(s) of the information:
b. Presenting psychiatric condition, current psychiatric treatment, medication and any
recent changes:
Source(s) of the information:
c. Recent stressors:
Source(s) of the information:
d. Substance use (type and treatment)
Source(s) of the information:
e. Prior psychiatric hospitalizations or voluntary outpatient treatment (types and dates
if known):
Source(s) of the information:
f. Prior medical and psychiatric diagnoses:
Source(s) of the information:
g. Prior treatment by an outpatient provider pursuant to a commitment for outpatient
treatment, if any; identifying dates of treatment; provider; any barriers to treatment;
and significant outcomes:
Source(s) of the information:
Effective 9/30/2014 Clinical/Screening Certificate Page 7 of 15
V. Results of Personal Examination
1. Present Mental Status:
a. Appearance and Attire:
b. Attitude and Behavior:
c. Affect and Mood:
d. Association and Thought Processes:
e. Thought Content:
f. Perception:
g. Sensorium, Memory and Orientation:
h. Intellectual Functioning:
i. Insight and Judgment:
Effective 9/30/2014 Clinical/Screening Certificate Page 8 of 15
2. Description of physical findings (include physical status, vital signs, laboratory data):
VI. Conclusions
1. Provisional Diagnoses from current Diagnostic and Statistical Manual:
Psychiatric and Substance Use Diagnosis/Diagnoses:
Other Diagnoses:
I certify that the patient will be dangerous to self (complete item VI.2) and/or
others or property (complete item VI.3) in the foreseeable future because of a mental
illness as defined in section I.
2. Dangerous to Self:
If you have concluded that this patient is dangerous to self, answer the items in (a), (b), and/or
(c) below that are relevant to the patient's condition, giving the sources of information by name
and title or relationship to patient, or cite the document. Give details, including history, recent
threats, dates and situations surrounding any attempts; i.e. was patient taking medication, under
supervision of a community treatment program, in the hospital, was there a precipitating crisis?
a. The patient has threatened or attempted to commit suicide (when and how, if known):
Source(s) of the information:
b. The patient has threatened or attempted serious bodily harm to himself/herself as follows:
Source(s) of the information:
Effective 9/30/2014 Clinical/Screening Certificate Page 9 of 15
c. The patient has behaved in the following manner which indicates that he or she is unable to
satisfy his/her need for nourishment essential medical care shelter:
and
The patient is not able to satisfy the needs listed in (c) above with the supervision and
assistance of others who are willing and available.
Source(s) of the information:
3. Dangerous to Others or Property
If you have concluded that this patient is dangerous to others or property, answer the items below,
giving the sources of information by name and title or relationship to patient, or cite the
document. State all facts, observations or information upon which you base your conclusion that
the patient, if not committed, would be substantially likely to inflict serious bodily harm upon
another person or cause serious property damage within the reasonably foreseeable future:
a. History of Dangerous Behavior:
Source(s) of the information:
b. Recent behavior (state date(s) of behavior)
Source(s) of the information:
4. State alternatives to involuntary treatment that were considered and why other services are not
appropriate or available to meet the patient’s mental health care needs. Be specific. If
information contained in the screening document is relied on, please refer to specific item number
in that document.
Effective 9/30/2014 Clinical/Screening Certificate Page 10 of 15
5. I am aware of the standard for involuntary commitment as defined in section I above. The
following checked statements are true:
I personally examined this patient.
This patient suffers from a mental illness as defined in section I of this form.
This patient, if not committed, would be a danger to self and/or others or property by
reason of mental illness in the foreseeable future.
This patient is unwilling to be admitted to the required treatment program or facility
voluntarily for care.
If you have checked all the boxes in number 5 (or the first three if the patient has consented
to admission to a short term care facility), proceed to Disposition in section VII. If not, refer
back to Screener for referral and follow-up.
VII. Disposition
1. If the patient is to receive services in a county that has not yet designated an outpatient
commitment program, or if the program exists but has no openings:
The danger s/he presents is imminent.
Although the danger s/he presents is not imminent, this patient is in need of care at a
psychiatric inpatient unit because other services are not appropriate or available to
meet the person's mental health care needs.
2. If the patient is to receive services in a county that has a functioning outpatient commitment
program, choose one of the two options below.
In my professional judgment, the danger is imminent, or outpatient treatment is either
not available or would not be sufficient to render the patient unlikely to be dangerous
in the reasonably foreseeable future, or the patient does not have a history of
responding to treatment, and my recommendation is commitment to the least
restrictive available inpatient facility.
Or
In my professional judgment, the danger is foreseeable, but not imminent, and my
recommendation is commitment to an available outpatient program provided by:
The following are essential elements of any treatment plan implemented with this patient
by an outpatient treatment provider:
medication monitoring @
group therapies:
individual therapy @
case management
residential supervision
Effective 9/30/2014 Clinical/Screening Certificate Page 11 of 15
(Describe intensity of supervision required)
other services and programs required to maintain or lessen current level of
dangerousness:
VIII. Certification
I certify that the foregoing statements made by me are true.
I further certify that this patient is medically stable and is not in primary need of a medical or
nursing home level of care at this time.
I am aware that if any of the foregoing statements made by me are willfully false, I am subject
to punishment.
Date Psychiatrist/Physician’s Signature
Effective 9/30/2014 Clinical/Screening Certificate Page 12 of 15
IX. Change of Patient Status and/or Location
Please complete section A, B, or C to the fullest extent possible and forward to the appropriate
county adjuster.
CURRENT Status (check one)
Committed to Outpatient Treatment Conditional Extension Pending Placement
Committed to Inpatient Treatment Conditional Discharge
Voluntary Consensual
Current psychiatric hospital and unit or outpatient provider:
A. Change of Patient Status
PROPOSED status (check one)
Committed to Outpatient Treatment Committed to Inpatient Treatment
(new screening certificates must be attached if current status is CEPP, Conditional
Discharge, voluntary or consensual)
Conditional Extension Pending Placement Voluntary Consensual
Judge who entered order now in effect and date:
Hon.
(Name) (Date)
Copy of most recent court order must be attached.
B. Change of Location (complete this section if the program with responsibility for a patient’s
care is proposing a transfer to a different location for treatment).
1.a. The patient’s attorney’s name:
b. Date and manner of notification to patient’s attorney of his application:
Date (email, telephone, certified mail, fax, personal)
If patient is being transferred before an initial hearing, this notice must occur at least 24
hours before the transfer occurs.
Effective 9/30/2014 Clinical/Screening Certificate Page 13 of 15
2. Check all that apply:
Patient has insufficient financial resources to remain in current inpatient unit.
Patient needs longer term inpatient treatment than present hospital offers.
Patient needs program available at receiving hospital or program and NOT
available at current facility or through current program.
Patient requests transfer.
Patient's family requests transfer.
Other reason
Other information regarding patient's legal or hospitalization status:
(Signature) (Name Printed) (Title)
(Date)
C. Change from inpatient to outpatient commitment or from outpatient to inpatient
commitment
(Complete either SECTION 1 or 2)
1. If requesting a change from outpatient to inpatient commitment, describe:
a. behaviors that indicate increased risk of danger (attach incident or police reports as
available) such that dangerousness due to mental illness is both foreseeable and
imminent:
b. treatments attempted or ruled out
Effective 9/30/2014 Clinical/Screening Certificate Page 14 of 15
c. connection of danger to mental illness
d. The consumer
is materially compliant with the treatment plan approved by the court but no
modification of the treatment plan has been sufficient to reduce dangerousness.
is not materially compliant with the treatment plan approved by the court and a
modification of the treatment plan would be insufficient to reduce dangerousness.
Explain, including any attempts to modify the plan or the patient's compliance:
Treating Psychiatrist Printed Name Date and Time
I concur that the consumer requires inpatient treatment at this time.
Screening Psychiatrist Printed Name Date and Time
2. If requesting change from inpatient to outpatient, describe:
a. behaviors that indicate decreased risk of danger (attach treatment notes as appropriate)
b. treatment available at outpatient treatment program that program has agreed to provide:
c. CEO or a person designated by the CEO initiated Conversion on
(Date)
Effective 9/30/2014 Clinical/Screening Certificate Page 15 of 15
d. The patient
is still dangerous because of mental illness and unwilling to cooperate with
treatment, but the danger is no longer imminent
never presented an imminent danger but a program opening has developed that
was not available at the time of the original commitment order.
Treating Psychiatrist Printed Name Date and Time
X. For County Adjuster
If only a change in location is recommended, the adjuster is directed to amend the location in the
notice of hearing and any appropriate financial records to reflect the change to:
(New Location)
If change of status is requested, the adjuster is directed to submit this request with original
commitment papers to the courts and set down for a hearing in compliance with the statutes and court
rule.
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I. Definitions and Legal Standards (State of New Jersey)

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Completed 15 May 2021

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