Form Dmhas - Initial Incident Report Form October 2015 (Page 3 of 3) in pdf

Initial Incident Report Form

New Jersey Department of Human Services

Division of Mental Health & Addiction Services

Reports must be submitted no later than one (1) working day following the date the incident was known to the agency.

Submit reports to: dmhs.incidentrept@dhs.state.nj.us or Fax # 609-341-2324.

Consumer Name: _____________________________________ Incident Date: _____________

14) Has this consumer been discharged within the last 60 days from a STCF, CCIS, state, county or private psychiatric hospital

or another community mental health agency?

Yes, specify the hospital name and discharge date: ____________________________________________________

15) Does this consumer have any legal/criminal status?

Yes, specify status: ______________________________________________________________________________

16) Diagnoses:

DSM Diagnoses: ______________________________________________________________________________________

______________________________________________________________________________________

Medical Diagnoses: ___________________________________________________________________________________

___________________________________________________________________________________

17) ASAM Level of Care: ___________________________________________________________________________________

18) Medications:

Psychiatric Medications: _______________________________________________________________________________

_______________________________________________________________________________

Medical Medications: __________________________________________________________________________________

_________________________________________________________________________________

19) Notifications, including family, local law enforcement and Prosecutor’s Office:

Name: ____________________________ Title: _________________________ Date: ____________ Time: ____________

20) Immediate actions taken or other actions planned (include responsible party):

____________________________________________________________________________________________________

This document was prepared by: _______________________________________ Title: _______________________________

Date: ___________ Time: ___________ Phone number: _______________ E-mail address: ___________________________

Contact person if different than the preparer: _____________________________ Title: _______________________________

Phone number: _______________ E-mail address: ____________________________________

The information contained in this report is confidential. This document is for internal use only and is not a public document. Only those with a need to know and

authority to review this report may review the report. This report may contain confidential client information, as well as protected health information, which are

protected by state and federal confidentiality laws. Unauthorized disclosure of any of the contents of this report may result in civil and/or criminal penalties.

If you have received this in error, please call 1-800-382-6717 immediately.

Advisory, Consultative, Deliberative, Confidential Communication

NJ Department of Human Services 10-2015

Initial Incident Report Form

DMHAS