Submit
Cancel
LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
1. The right to be free from unnecessary or excessive medication (see N.J.A.C. 10:37-6.54)
2. The right to not be subjected to non-standard treatment or procedures, experimental procedures or research,… or provider demonstration programs, without written informed consent, .
i. If the client has been adjudicated incompetent, authorization for such procedures may be obtained only pursuant to the requirements of N.J.S.A. 30:4-24.2(d)2.
3. The right to treatment in the least restrictive setting, free from physical restraints and isolation…
4. The right to be free from corporal punishment.
5. The right to privacy and dignity.
6. The right to the least restrictive conditions necessary to achieve the goals of treatment/services.
Each client shall be made aware of the existence of a complaint procedure at second, non-emergency contact. Written notice, as well as a verbal explanation of agency complaint procedures, and external advocacy services which are directly available to clients at all times, shall be given to each client at the earliest appropriate opportunity. Under all circumstances, clients not accepted for services shall be informed immediately of the State-wide advocacy services available to them. Information regarding external advocacy services shall minimally include the: [N.J.A.C. 10:37-4.6(b)1]

i. Community Mental Health Law Project);
225 East State Street, Suite 5
Trenton, NJ 08608
Phone: (609) 392-5553
Fax/TTY: (609) 392-5369
E-mail: Trenton@chlp.org
Managing Attorney: Stacy Noonan
Supervising Advocate: Jacqueline Darby

ii. County Mental Health Administrator in the county;
Michele Madiou, Mental Health Administrator
Phone: 609-989-6574
Fax: 609-989-6032
Mail: 640 S. Broad Street
P.O. Box 8068
Trenton, NJ 08650-0068
Email: mmadiou@mercercounty.org

iii. Division of Mental Health Services' Ombudsperson;
Susanne Mills
5 Commerce Way
P.O. Box 362
Hamilton, NJ 08625
609-438-4321

iv. Division of Mental Health Advocacy;
State of New Jersey
Division of Mental Health Advocacy
Justice Hughes Complex
25 Market Street
Trenton, New Jersey 08625
(877)285-2844

v. Division of Youth and Family Services (for abuse a or abuse and/or neglect);
Mercer North LO #673
3131 Princeton Pike
Building 6, Suite 202
Lawrenceville, NJ 08648
609-530-7200
800-392-2735
Fax: 609-530-0203
Manager- Brandi Harding

vi. County Welfare Agency (for adult abuse).
Mercer County Board of Social Services
200 Woolverton Street
Trenton, NJ 08650
Phone: 609-989-4346
After Hrs: Call local police or 911 in case of emergency
www.mcboss.org
by signing below you are indicating that you have received and understand the information included on this form.
Patient and Witness to sign form
Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.