Skip navigation
For Assistance - 24 Hours a Day - 7 Days a Week: Please contact us at 1-877-652-7624

Forms

Clinical summary template

Providers complete the clinical summary template (DOC) to assist in the determination of an appropriate intensity of service in the management of a youth's emotional and behavioral needs. It is used for any of the following reasons:

  1. Connecting with New Jersey Children’s System of Care (CSOC) Care Management services.
  2. A supplemental document for care management-linked youth, who currently receive community-based therapeutic services, and are referred for out-of-home treatment.
  3. Potential linkage to other CSOC services.

If you need more information regarding the clinical summary template (DOC), or referring a child for CSOC services, call PerformCare at 1-877-652-7624.

Individual Support Services - CABS

ADLs consist of self-care tasks and Instrumental ADLs enable an individual to live independently in the community. An Individual Support Technician must arrange to meet with the parent/legal guardian/custodian and jointly complete the Child Adaptive Behavior Summary (CABS).

Initial Assessment for Substance Use Treatment

As part of the new substance use authorization process, substance use treatment providers are required to use the new Substance Use Treatment Initial Assessment form (PDF). All documents should be faxed to the PerformCare substance use provider fax number at 1-877-949-6590. The 42 Code of Federal Regulations (CFR) consent forms must be faxed on the first day of admission, and the initial clinical assessments should be faxed within the first 30 days of admission. The clinical documents must provide clinical justification for the youth's treatment at the requested intensity of service.

Intensity of service dispute form

For instances when providers wish to dispute PerformCare's intensity of service (IOS) determination.

Out-of-home (OOH) referral packet checklist

For instances when a provider is referred to the Division of Children's System of Care, CSOC specialized residential treatment unit (SRTU) or is requesting a Tier II Consultation.

Release of information form

To be completed by the family and faxed to PerformCare at 1-877-736-9166 to request a release of a youth's medical record.

Service desk request form

An online form that can be completed to address CYBER technical issues, eligibility questions, provider information, etc. Please have your Medicaid number available.

Tier II Consultation form

In instances where providers are requesting a Tier II Consultation determination.

Transitional Joint Care Review (TJCR)

For instances when the Child Family Team agrees that a transition from one OOH provider to another will best meet the needs of the child, a Transition Joint Care Review (TJCR) is created.