Form USTF-5 "Unified Services Transaction Emergency / Screening Registration" - New Jersey

What Is Form USTF-5?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 1989;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form USTF-5 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form USTF-5 "Unified Services Transaction Emergency / Screening Registration" - New Jersey

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UNIFIED SERVICES TRANSACTION
INSTRUCTIONS:
PLEASE TYPE ENTRIES 1. THROUGH 5.
EMERGENCY / SCREENING
1. PROJECT NAME:________________________________________________
>REGISTRATION<
2. PROJECT CODE
3. CLIENT/PATIENT NO.
4. DATE OF BIRTH
5. UNIQUE CLIENT ID
MONTH
DAY
YEAR
21. CURRENT TYPE
31. PROGRAM / SERVICE NEEDS
41. RESIDENTIAL
INSTRUCTIONS:
HANDPRINT
OF EDUCATION
( Circle up to 10 )
ARRANGEMENT AT
CLEARLY IN BOXES AND CIRCLE
TERMINATION
LETTERS FOR MULTI-RESPONSE
A
B
C
D
E
QUESTIONS 6. THROUGH 51. SEE
22. SOURCE OF REIMBURSEMENT
F
G
H
J
K
CODES ON REVERSE.
( Circle up to 4 )
. PRIMARY AGENCY
42
L
M
N
O
P
A
B
C
D
E
RESPONSIBLE FOR
6. ZIP CODE
R
S
T
V
W
F
G
H
FOLLOW-UP SERVICES
X
1
2
7. CO-MUN CODE
OF RESIDENCE
23. INCOME SOURCE
32. LEVEL OF
(Circle up to 8)
43. M.H. AGENCY / HSP. CODES
FUNCTIONING AT
A
B
C
D
E
INITIAL CONTACT
8. SERVICE AREA
F
G
H
J
OF RESIDENCE
A-PRIMARY
B-SECONDARY
33. PRESENTING PROBLEMS
24. GROSS ANNUAL FAMILY
( Circle up to 17 )
INCOME
A
B
C
D
E
9. PROGRAM ELEMENT
44. CIRCUMSTANCE AT
0 0 0
F
G
H
J
K
TIME OF TERMINATION
L
M
N
O
P
25. TOTAL PERSONS
R
S
T
V
W
10. DATE OF FIRST FACE-TO-
DEPENDENT
FACE CONTACT
X
1
2
3
4
45.
ON INCOME
PRINCIPAL DIAGNOSIS
5
6
7
8
9
26. S.S. ELIGIBILITY
MO
DA
YR
34. PRIMARY PRESENTING
PROBLEM
46. SECONDARY DIAGNOSIS
11. REFERRAL SOURCE
27. PAST SERVICE HISTORY
35. HANDICAPPING CONDITIONS
( Circle up to 12 )
( Circle up to 7 )
A
B
C
D
E
12. SEX
A
B
C
D
E
F
G
H
J
K
47. PHYSICAL DIAGNOSIS
F
G
H
J
K
M - Male
L
M
N
O
P
F - Female
R
S
T
V
W
X
1
2
3
4
13. RACE / ETHNICITY
5
6
48. LEVEL OF FUNCTIONING AT
36. CO-MUDE CODE
LAST CONTACT
WHERE CLIENT
28. CURRENT SERVICE INVOLVE -
WILL RESIDE
14. ENGLISH SPEAKING
( Circle up to 12 )
MENT
49. EMERGENCY CONTACTS
A
B
C
D
E
37. SERVICE AREA
FACE-TO-FACE
F
G
H
J
K
WHERE CLIENT
15. MARITAL STATUS
L
M
N
O
P
WILL RESIDE
R
S
T
V
W
50. SCREENING
X
1
2
3
4
16. LIVING CIRCUMSTANCE
38. PROGRAM ELEMENT
CONTACTS
5
6
39. TERMINATION DATE
17. RESIDENTIAL
29. HOSPITAL DISC-
51.
OPTIONAL / SPECIAL USE
ARRANGEMENT
HARGED FROM
IN LAST 30 DAYS
MO
DA
YR
18. VETERAN
30. NON-MENTAL HEALTH NEEDS
40. LIVING CIRCUMSTANCES AT
52.
FUTURE USE
( Circle up to 5 )
( Circle one )
TERMINATION
Y - Yes
A
B
C
D
E
N - No
F
G
H
J
K
A – Alone / Independent
L
M
N
P
B – With Relatives / Family
53. TRANSACTION TYPE
19. EMPLOYMENT STATUS
C - Other
1
20. EDUCATION
SIGNATURE OF PERSON COMPLETING FORM
DATE
(Highest grade level)
NEW JERSEY DEPARTMENT OF HUMAN SERVICES – Division of Mental Health and Hospitals
FORM NO. USTF-5 (07/89)
DISTRIBUTION:
1 COPY – N.J. DEPT. of HUMAN SERVICES
2 COPY – AGENCY COPY
UNIFIED SERVICES TRANSACTION
INSTRUCTIONS:
PLEASE TYPE ENTRIES 1. THROUGH 5.
EMERGENCY / SCREENING
1. PROJECT NAME:________________________________________________
>REGISTRATION<
2. PROJECT CODE
3. CLIENT/PATIENT NO.
4. DATE OF BIRTH
5. UNIQUE CLIENT ID
MONTH
DAY
YEAR
21. CURRENT TYPE
31. PROGRAM / SERVICE NEEDS
41. RESIDENTIAL
INSTRUCTIONS:
HANDPRINT
OF EDUCATION
( Circle up to 10 )
ARRANGEMENT AT
CLEARLY IN BOXES AND CIRCLE
TERMINATION
LETTERS FOR MULTI-RESPONSE
A
B
C
D
E
QUESTIONS 6. THROUGH 51. SEE
22. SOURCE OF REIMBURSEMENT
F
G
H
J
K
CODES ON REVERSE.
( Circle up to 4 )
. PRIMARY AGENCY
42
L
M
N
O
P
A
B
C
D
E
RESPONSIBLE FOR
6. ZIP CODE
R
S
T
V
W
F
G
H
FOLLOW-UP SERVICES
X
1
2
7. CO-MUN CODE
OF RESIDENCE
23. INCOME SOURCE
32. LEVEL OF
(Circle up to 8)
43. M.H. AGENCY / HSP. CODES
FUNCTIONING AT
A
B
C
D
E
INITIAL CONTACT
8. SERVICE AREA
F
G
H
J
OF RESIDENCE
A-PRIMARY
B-SECONDARY
33. PRESENTING PROBLEMS
24. GROSS ANNUAL FAMILY
( Circle up to 17 )
INCOME
A
B
C
D
E
9. PROGRAM ELEMENT
44. CIRCUMSTANCE AT
0 0 0
F
G
H
J
K
TIME OF TERMINATION
L
M
N
O
P
25. TOTAL PERSONS
R
S
T
V
W
10. DATE OF FIRST FACE-TO-
DEPENDENT
FACE CONTACT
X
1
2
3
4
45.
ON INCOME
PRINCIPAL DIAGNOSIS
5
6
7
8
9
26. S.S. ELIGIBILITY
MO
DA
YR
34. PRIMARY PRESENTING
PROBLEM
46. SECONDARY DIAGNOSIS
11. REFERRAL SOURCE
27. PAST SERVICE HISTORY
35. HANDICAPPING CONDITIONS
( Circle up to 12 )
( Circle up to 7 )
A
B
C
D
E
12. SEX
A
B
C
D
E
F
G
H
J
K
47. PHYSICAL DIAGNOSIS
F
G
H
J
K
M - Male
L
M
N
O
P
F - Female
R
S
T
V
W
X
1
2
3
4
13. RACE / ETHNICITY
5
6
48. LEVEL OF FUNCTIONING AT
36. CO-MUDE CODE
LAST CONTACT
WHERE CLIENT
28. CURRENT SERVICE INVOLVE -
WILL RESIDE
14. ENGLISH SPEAKING
( Circle up to 12 )
MENT
49. EMERGENCY CONTACTS
A
B
C
D
E
37. SERVICE AREA
FACE-TO-FACE
F
G
H
J
K
WHERE CLIENT
15. MARITAL STATUS
L
M
N
O
P
WILL RESIDE
R
S
T
V
W
50. SCREENING
X
1
2
3
4
16. LIVING CIRCUMSTANCE
38. PROGRAM ELEMENT
CONTACTS
5
6
39. TERMINATION DATE
17. RESIDENTIAL
29. HOSPITAL DISC-
51.
OPTIONAL / SPECIAL USE
ARRANGEMENT
HARGED FROM
IN LAST 30 DAYS
MO
DA
YR
18. VETERAN
30. NON-MENTAL HEALTH NEEDS
40. LIVING CIRCUMSTANCES AT
52.
FUTURE USE
( Circle up to 5 )
( Circle one )
TERMINATION
Y - Yes
A
B
C
D
E
N - No
F
G
H
J
K
A – Alone / Independent
L
M
N
P
B – With Relatives / Family
53. TRANSACTION TYPE
19. EMPLOYMENT STATUS
C - Other
1
20. EDUCATION
SIGNATURE OF PERSON COMPLETING FORM
DATE
(Highest grade level)
NEW JERSEY DEPARTMENT OF HUMAN SERVICES – Division of Mental Health and Hospitals
FORM NO. USTF-5 (07/89)
DISTRIBUTION:
1 COPY – N.J. DEPT. of HUMAN SERVICES
2 COPY – AGENCY COPY
9
1 7. and 41. RESIDENTIAL
2 7. and 28. (continued)
3 3. and 34. (continued)
. and 38. PROGRAM ELEMENT
J
A.
Private Residence
.
Family Crisis Intervention Unit
R.
Marital/Family Problem
C.
Designated Screening
B.
Cooperative Living Situation
S.
Medical/Somatic Complaints
K.
Child Study Team Evaluation
D.
Emergency
(No MH Svcs)
T.
No Social Support Resources
L.
Group Home With MH Services
C.
Foster Family Care
V.
Organic Mental Disorder
M.
Specialized Foster Care
D.
Homeless/On Street
W.
Physical Abuse/Assault Victim
N.
Public Welfare
E.
Community Residential Program
X.
Physical Neglect
O.
Other Social Service Agency
11. REFERRAL SOURCE
(With MH Svcs)
1.
Runaway Behavior
P.
State Psychiatric Hospital
EMERGENCY / SCREENING /
F.
Boarding Home/RHCF
2.
School Problems
R.
County Psychiatric Hospital
INPATIENT
G.
Nursing Home/SNF/ICF
3.
Sexual Abuse/Rape Victim
S.
CCIS Inpatient
A.
Designated Screening Center
H.
Residential Substance Abuse Pgrm.
4.
Sexual Abuser
T.
Other Psychiatric Inpatient
B.
Emergency
J.
DDD/MR Residence
5.
Social/Interpersonal (Non-family)
V.
Clinical Case Management /
C.
CCIS Inpatient
K.
DYFS Residential Treatment Ctr.
6.
Suicide Attempt
Youth Case Management
D.
County Psychiatric Hospital
L.
Children’s Group Home /
7.
Suicide Threat
W.
Outpatient /Counseling
E.
State Psychiatric Hospital
Teaching Family Program
8.
Thought Disorder
X.
Partial Care
F.
Other Psychiatric Inpatient
M.
Homeless Shelter
9.
Other
1.
Residential Care
G.
General Hospital
N.
Other Residential Program
2.
Emergency Mobile Outreach /
O.
State Psychiatric Hospital
3 5. HANDICAPPING CONDITIONS
Treatment Team
COMMUNITY PROGRAMS/
P.
County Psychiatric Hospital
3.
Liaison Services
A.
Ambulatory/Orthopedic
RESIDENTIAL SOURCES
R.
CCIS Inpatient
4.
System Advocacy
B.
Auditory
H.
Community M. H. Agency
S.
Other Psychiatric Inpatient
5.
Self Help Services
C.
Communication
J.
Alcohol Treatment Program
T.
State Correctional Facility
6.
None
D.
Developmental Disability/MR
K.
Drug Treatment Program
V.
Detention Center
E.
Neurologically Impaired
L.
School System
W.
Other Institutional Setting
F.
Medical
M.
Other Social Service Agency
X.
Unknown
3 0. NON-MENTAL HEALTH NEEDS
G.
Visual
N.
Nursing Home
H.
Emotionally Disturbed
A.
Alcohol Abuse Services
O.
Boarding Home
(Ed. Classification Only)
B.
Correctional
1 9. EMPLOYMENT STATUS
P.
Homeless Shelter
J.
Perceptually Impaired
C.
Drug Abuse Services
R.
Other Residential Program
A.
Employed – Full – Time
(Ed. Classification Only)
D.
Education
B.
Employed – Part – Time
K.
None
E.
Employment
LEGAL /JUSTICE SYSTEM
C.
Armed Services
F.
Financial
S.
Police / Court / Jail
D.
Sheltered Employment
4 2. PRIMARY AGENCY
G.
Housing
T.
State Correctional Program
E.
Unemployed
H.
Legal/Justice
SCREENING / INPATIENT
V.
Community Correctional Program
F.
Not in Labor Force
J.
Medical/Health Related
A.
Designated Screening Center
W.
Family Crisis Intervention Unit
G.
Unknown
K.
Pastoral
B.
Short term Care Facility
L.
Recreation
C.
CCIS Inpatient
INDIVIDUALS
2 1. CURRENT TYPE OF EDUCATION
M.
Transportation
D.
Country Psychiatric Hospital
X.
Self
A.
Regular / Vocational Education
N.
Other
E.
State Psychiatric Hospital
1.
Family or Friend
B.
Special Education
P.
None
F.
Other Psychiatric Inpatient
2.
Private M. H. Practitioner
C.
Post High School Education
G.
General Hospital
3.
Private Psychiatrist
D.
Not in School
COMMUNITY PROGRAMS /
4.
Medical Doctor
3 1. PROGRAM / SERVICE NEEDS
RESIDENTIAL SOURCES
5.
Clergy
2 2. SOURCE OF REIMBURSEMENT
H.
Community Mental Health Agency
A.
Crisis Stabilization/ Emergency
J.
Alcohol Treatment Program
DEPT. OF HUMAN SERVICES
A.
None – Organization to absorb
Services
K.
Drug Treatment Program
6.
DYFS
total cost
B.
CCIS Inpatient
L.
School System
7.
DDD
B.
Self/Legally Responsible Relative
C.
Other Psychiatric Inpatient
M.
Other Social Service Agency
8.
Other
C.
Medicaid
D.
Client Advocacy
N.
Nursing Home
D.
Medicare
E.
Dally Living Skills
O.
Boarding Home
E.
Other Public Sources
F.
Medication Monitoring/Education
P.
Homeless Shelter
F.
Service Contract (e.g., HMO)
G.
Partial Care
R.
Other Residential Program
13. RACE / ETHNICITY
G.
Other Third Party Insurance
H.
Psychological / Psychiatric
LEGAL / JUSTICE SYSTEM
H.
Unknown
Evaluation Only
A.
American Indian/Alaskan Native
S.
Police / Court / Jail
J.
Psychotherapy / Counseling
B.
Asian / Pacific Islander
T.
State Corrections Program
K.
Self-Help Services
C.
Black, Not of Hispanic Origin
V.
Community Corrections Program
L.
Service Coordination / Linkage
2 3. INCOME SOURCE
D.
Hispanic
W.
Family Crisis Intervention Util
M.
Community Residential Program
E.
White, Not of Hispanic Origin
A.
Disability Insurance / Workman’s
INDIVIDUALS
(With MH Svcs)
F.
Other
Comp.
X.
Private Mental Health Practitioner
N.
Crisis Housing
B.
Family or Relative
1.
Private Psychiatrist
O.
Outreach / In-Home Services
C.
Pension
2.
Medical Doctor
P.
Residential Support Services
D.
Public Assistance
3.
Clergy
S.
Pre-Vocational Services
14. ENGLISH SPEAKING
E.
Social Security
DEPARTMENT OF HUMAN SERVICES
T.
Transitional/Supported Employment
F.
Unemployment Insurance
4.
DYFS
V.
Child Study Team Evaluation
A.
Yes
G.
Wage/Salary Income
5.
DDD
W.
DDD
B.
No. Spanish Speaking
H.
Other
6.
Other
C.
No. Other Foreign Language
X.
DYFS
J.
Unknown
7.
No Referral
1.
Information and Referral
D.
No. American Sign Language
2.
Other
2 6. S. S. ELIGIBILITY
4 4. CIRCUMSTANCE
A.
Determined Eligible
3 3. Problems and 34. Primary Problem
A.
Termination With Referral
B.
Potentially Eligible
Termination without Referral:
15. MARITAL STATUS
A.
Alcohol Abuse
C.
Probably Not Eligible
B.
No Further Services Needed
B.
Anxiety
A.
Married/Living as Married
D.
Determined to be Ineligible
C.
Further services Needed But Not
C.
Assaultive Behavior/Threat
B.
Widowed
Available / Treatment Goal Met
D.
Bizarre Behavior
C.
Divorced
D.
Further services Needed But Not
E.
Compulsive Gambling
D.
Separated
27. PAST SERVICE HISTORY and
Rejected By Client
F.
Dally Living Problems
E.
Never Married
2
8. CURRENT SERVICE INVOLVEMENT
E.
Further services Needed But
G.
Depression/Mood Disorder
F.
Unknown
Rejected By Parent / Guardian
A.
Alcohol Treatment Program
H.
Destructive to Property
F.
Client Lost To Contact, Follow-Up
B.
Drug Treatment Program
J.
Developmental Disability
Attempted, No Contact Made
C.
Community Corrections Program
K.
Drug Abuse
G.
Client Lost To Contact, No Follow-Up
D.
Correctional Facility
L.
Eating Disorder
16. LIVING CURCU MSTANCES
Attempted
E.
Detention Center
M.
Economic Stress
A.
Alone/Independent
H.
Client Moved / Known to Be Unaval.
F.
Probation
N.
Fire Setting/Ideation
B.
With Relatives/Family
J.
Client Died On Premises
G.
DDD
O.
Homicidal Behavior/Threat
C.
Other
K.
Client Died Off Premises
H.
DYFS
P.
Legal/Justice Involvement
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