ࡱ> PRO bjbjUU 4??||_Wn Z X/0_gggH0"(D _g| : STATE OF NEW JERSEY  DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH SERVICES SCREENING OUTREACH REQUEST FOR POLICE TRANSPORT AND SUPERVISION PURSUANT TO N.J.S.A. 30:4-27.6b.* I am a New Jersey Certified Mental Health Screener and an employee of _________________________________________________ (Designated Screening Service for _____________County) I certify that I have made an outreach visit and based on that visit I believe _____________________________ is in need of involuntary commitment, that is, that s/he is dangerous to self, others, or property because of a mental illness and is unwilling to go to the screening service on his or her own. (The transport is to a screening service for further assessment by a physician and disposition, which may include civil commitment.) Therefore, I request that ____________________________________ Police Department Transport ______________________________________to the Designated Screening Service located at __________________________________________________________ for a complete assessment. _________________________________________ Signature of Screener _________________________________________ Printed Name of Screener Date_______________________ Time __________am/pm * N.J.S.A. 30:4-27.6 (b) A State or local law enforcement officer shall take custody of a person and take the person immediately and directly to a screening service if: (b) A mental health screener has certified on a form prescribed the division that based on a screening outreach visit the person is in need of involuntary commitment and has requested the person be taken to the screening service for a complete assessmentThe involvement of the law enforcement authority shall continue at the screening center as long as necessary to protect the safety of the person in custody and the safety of the community from which the person was taken. 3Wj  4 5 6 L S l m n ^ °uj_ujTujujujuju_ujuh/5OJQJ^Jh`X5OJQJ^Jh=5OJQJ^JhFD5OJQJ^JhFD5CJOJQJ^JaJhG,5CJOJQJ^JaJ#hFDhFD5CJOJQJ^JaJ#hFDhFD5CJ OJQJ^JaJ #hFDhFD5CJ(OJQJ^JaJ(hFDhFD5OJQJ^J!jhFDh=OJQJU^JhFDhFDOJQJ^J3VWj  5 6 n o ( ) * | }  6  `'gd/gd`XgdFD$a$gdFD & ' ( ) { ~  / 0 A I s w   , - E ȽȽȽȽȫ#h`Xh`X5CJOJQJ^JaJh!5CJOJQJ^JaJ#h`Xh=5CJOJQJ^JaJh/5OJQJ^Jh=5OJQJ^Jh`X5OJQJ^JhFD5OJQJ^Jh5OJQJ^JhG,5OJQJ^J&6 7 s + , gdFD 21h:p=/ =!"#$% ]FDd T  C 0Astate-seal2REJՒݭ*JJ$EDFEJՒݭ*JJ$JFIFddDucky7Adobed     ########## ################################################# !1A"Q2aqB#R3b$Cr4%5҃DTU!1AQaq"2BRbrҲ#3S ?4h@<"D$gbxN~ifڼjZ8xf&CnO^FOHT'\kIף\#6QOy*+ɧth*d>ّA}R@IE -(*gR1&[\7+pʽi =`=|b3s!ږ'fv?$?QH@ 4h@ 4h?7|L6QNA4'jcN妐]͉K흒fWl=vVUL=".r;>cV^97QEgvqP?Ř X4'6t {K{p3;Z9V>ֿ\BgyixmfPB$nԐGݨ͠@ 4h@*p=v[3VCJchSZuV_p$x; pM27Hmק4j@YS~f-pv1^ XLLr\k!t!LN5g"v>K [Z=Yw|M0ЃX^GOn2>7) }o8 CMPsx'ı s_l*ᤜE1 v5%:%; _8I5=+X6UC8SޞfzѨhM,,qGٗ#-.MrGţH'=ʵۮ#: Vp]HEל//o8}+6)C]V$2|r}ܧ%QFbk,3 P*"ZH:t3nO[e9U7-0Øg1mἵvWEڀȒz^u<+=&?[K̟ul-&P"2кd{UzAZR>fa\FrbjQKPjB+|M%w>]H{yPVH-dW4=g -=էFh&E`=h@  Thg9V{[:enTڷu8TY|[t*=ud\iX,6(#ea[P$ҕ!Mc{w8*LBm5 KS hq} xIqjD6ċAP(ҫڊMOH w6Y;Y,r6]L6o:,h< M6o,3G NU}fP(ϒAs"O=Ǫ^ʦ2ŀBO*n(E˖ӏ^4mؑZT!h%Wx(mkRŋn w/plp'#-s _fm2\|k/;ɵPCyB+DVXO%̀SFd5ōxY(Wit(5wYkh=x~bX/疀Y䧌~MEc]_Ck)i헺 /p/ٞ(/(*v;z>E-Da@ 4DͲ97<!4vYa-@H5`g&f|qqXBٸDG{{VYk_6Ĺ˓%,%1IS')b29-汵5t?So чz-jj# 4h)r@M.DDm2q-?u'R8'pLp g9Vzj^Rl W1`d%k6HhY"2Đ۸UrF*HRW܋|;{ass2cX݌X A1%RiऱMI*f8½JyFG_Q!1 '͋]A܇#v,rJ^q] APk:V5q 9$6# İO4SDn&3tvZ9k8r+7-+%чP=ȥ8>a@O(9OJF1d-a*X#0Uw*VAMب!&SݮKW1#[[,mvF{d!Y#w5YC J\CaƌJxnP\1'q)-^r1ȱʑ2J=,~_"TRȽHqtG7 ba1[^(THNEF$*տZ63ݹEUgft(Qߙ#(QkצT]eJ֦g[v屗)LGƋ,2B+i;qKTqupy9~ ˙y:;U>*><{*ZLĸc~fC|;wvMiP .}s\nKŲqq5#͢*|?K.YL}b]dm݈fE @|Uˌr ټ\A|{js S|Sz>j'4,7ky?$b_ӲƙW΂6i=λ@ )ӄ|{$4-n@Pw}!@%AЯM+T^9x\]30R=E*6OO'**T-A8L[Q4{7VRRzz)< 0uF8g,YܬbKp oqxpCWk"22yr^8&cNcg\29kF Qp-c\?1oa\%R[rģ[zX *.~wx6FՆT)p5&th337>Qu].i=DE a,s7y5ȸ_.t+nGW* ~:r`9W%qY\r.Gif$]RCjFHmP mxw ȭŎ2U]R8tߕrR֖~~\0_thݢ4IZ-:XҠncUH96|[`xTU$(WwX.&g"Z2Kc`M1u3N%1$d.2GcbxE.:}]V+cdi3KV(T 3yҖ-mXREsy!*\ ܼdbŅTj+W]:]Qe^7X]_k.#2H܌Ѝon.8Z\rh+WBq jѼ|:PW%Vo\/ r#gA ge mSn+;t|qebZ@ώr2B!X7Ǯ-<*5ۊM 9)岰[k}%opdY" 1Щ ^*j1jd[pF"m zS/-Z ٹFS̥dYŝ7ۇ=nEG4Ӡr̯2spr $Qd\Z[Ï\3\OU0Hx𠍮cS-,\r~)2dL141"⦖L m48қFSӢ{ݡ 幡8_:H 0H&5y4`Pa ;2'RwǯV|>-^En9W/3'clL.J>:++)P|"PkOi5ozW'HjkZt(23&{!X ')Ga.DءX%n!h'ge [3SYmAoUia瀽%71cnBI2ÎW詛V558'{8&V!gi W%﶑vwl+J|Ei;7j"[Utą8KNJD@AIUfknZrI+$ Mq# {mmڱ4$v>M \- d6y?mLl^9w]qV:rMQ<_7؞"}!24U ы S+{(ir_22hrmlZT+3+1ݚDQFSn) ]*4MHf+額U6oXMlvXý +7E(GOW+ '2,W۫ymZ7f~pz/A˷ŝwcn+ -X>,M%Ϡ`1u02:X2/79.3k.ox42b嶊7PMj4_޶JIø\|XL67^L)X-a+Ӹvx9F)W>Ņq687l)35>0N" U4zjN69 岼o5[0k"KwEIs-<.dfF[Km/*w<%/m3HU)0En-94v(`HGV#! +PuQ"Q#)=֪A#ڑD c)'\C.Вs]JY  .+^6XZc֑gDy%EIO SC/_^37< 2f~%^>I!qOrz۵ap=G?d/_'{`:Ũ> 5nɹ?lQ_Gǥ3&-$?v18hCC?xD7V>,qN>}̎ߥgq\C#lquUg|rrk_ܟr1j K\ !Tt#O[xRyf3LAqZ*U2cssemOMW(ě+e{Yb@Iӻ 7m[\-wK'ҝ;Ztx4$JMM;[qqMy,Zoq.lyEWv0vŴ֯ڜ{6`uShO)v5:,\2ǘ51O]ГoCvٷ wI[<ưqf[s DoX^ >=-Ҩ_ɑ{٧uԽd-.<>jMB>+ dڴ <[,ۖ=9PĂXR]5vt])F.K)<2qi!WU;v0 QSDe ]cq wPx9)qh@<(K6JrMwyT h.9Q)4I%OפJ՟JItMq{L!;m'+i QVgp\ר֤ l:{%!,baa+]4JXEdfg5)*! ~c=ǷVr (i͍Ԟ] .8pm9~2 ۞\u2$b9h o80hn30 1˄7*ݓ-qټ< Cݎ5#0 9׷܋vխp=!ݩIew< w}1.U^F*JSQ`Dd({:qnAD(u)_T_P9%/!ɰP+`F2R)3~!֥mrmK^XN ¸odHF+5`Brx<)yasqLŽ[JWeV!Ք0R^kY$hġ6Gd# Yf1} Z:F|Y=+3 T%E @ۮv{ͮ]^9 d67*“ƛX*pN1z=᫩iˊg\JowJ9d-_-%^ 6:^bEꓦ7ญ[r8FhпM6zhY]+iZhnT$u/8f8=%qA9Ckb1"PRFu٪6}˘LJ<\Ԕ5cLt|oqϊʵĶظ W0:^+T}iw 36[xXĐEnzY1#t-q2sMd" L 6: [Sx ,O)O_ݩC11ӂM F @i]izLKtRqҗw] KAN̒$xLS9'ɫVtbV-W'{g4h>2p! 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