Confirmation of substance exposure is required prior to making a notification.

Please contact DCP&P to make a report of abuse or neglect at 1-877-NJABUSE.

Please offer and connect the birthing individual to the Maternal Wrap Around Program (M-WRAP)

For Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, and Salem counties:

The Cooperative

Project Embrace/MWRAP

2500 McClellan Ave, Suite 250, Pennsauken, NJ 08109

Contact: Quinn Ingemi, qingemi@snjpc.org, 856-665-6000

Contact: Samantha Henhaffer, shenhaffer@snjpc.org, 609-605-0462

For Monmouth and Ocean counties:

JSAS HealthCare, Inc.

Maternal Wraparound Program

685 Neptune Boulevard, Suite 101, Neptune, NJ 07753

Contact: Rebecca Greene, rgreen@jsashealthcare.org, 732-988-8877

Contact: Sheri Huntley, shuntley@jsashealthcare.org

For Essex, Mercer, Middlesex, Hunterdon, Hudson, Somerset, and Union counties:

Rutgers University Behavioral Health Care

Maternal Wraparound Program

671 Hoes Lane West, Piscataway, NJ 08855

Contact: Brenda Oscar Stoddart, Program Coordinator, stoddabr@ubhc.rutgers.edu, 732-853-4046, 732-241-9028

Contact: Jeanmarie Leitch, Program Director, 732-267-9281

For Morris, Sussex, and Warren counties:

Zufall Health Center

Maternal Wraparound Program

18 W. Blackwell Street, Dover, NJ 07801

Contact: Nettie Mendez, nmendez@zufallhealth.org, 973-328-3344 ext. 1307

Contact: Sarah Aleman, saleman@zufallhealth.org, 973-328-9100 ext. 1322

For Bergen and Passaic counties:

Care Plus NJ, Inc.

Maternal Wraparound Program

610 Valley Health Plaza, Paramus, NJ 07652

Contact: Grace Del Colliano, graced@careplusnj.org, 201-265-8200 ext. 5529, 551-252-1418

If the birthing individual has other children in their care and abuse or neglect is suspected, please contact 1-877-NJABUSE to make a report to Child Protection and Permanency. At the birthing event, please call DCP&P if abuse or neglect concerns are indicated or return to this site to complete a notification form for substance affected infants where there are no concerns of abuse or neglect.

Provide the family with information for Connecting NJ at 609-292-4265. Connecting NJ is a network of partners and agencies dedicated to helping NJ families thrive by providing referrals to community resources, programs, and services.

Please link the family to Connecting NJ at 609-292-4265. Prior to discharge, complete a Family Care Plan. Connecting NJ is a network of partners and agencies dedicated to helping NJ families thrive by providing referrals to community resources, programs, and services.

Healthcare Provider Information

Healthcare Provider's First Name

Healthcare Provider's Last Name

Healthcare Provider's Email Address

Healthcare Provider's Phone Number

Healthcare Provider's Role Value is not selected

Define "Other"

Name of Hospital or Birthing Center Value is not selected

Information about the Infant

Has the birth event happened?

Yes

No

Has substance exposure been confirmed?

Yes

No

What method was used to confirm substance exposure?

Confirmation level testing

Verbal confirmation from birthing individual

Was the infant exposed to alcohol?

Yes

No

Was the infant exposed to controlled substances?

Yes

No

Select all substances the apply:

Define "Other":

Has active use of illegal or non-prescribed substance use or misuse of prescribed substances been confirmed through parent report or toxicology without treatment?

Yes

No

Is the infant experiencing NAS/NOWS or withdrawal symptoms due to prenatal exposure to illegal, non-prescribed, misused, or undetermined substance?

Yes

No

Does the infant have a diagnosis or has been designated to be at risk of FASD?

Yes

No

Are there other concerns for the infant's safety upon discharge from the hospital?

Yes

No

Has prenatal substance exposure been confirmed through confirmation level testing?

Yes

No

Does the birthing individual have an untreated diagnosed substance use disorder or is illegal substance use indicated?

Yes

No

Infant Demographics

Race/ethnicity of the birthing individual (check all that apply)

American Indian / Alaska Native

Asian

Black / African America

Multi-Racial / Other Race Unknown

Native Hawaiian / Other Pacific Island

Hispanic / Latino

White / Caucasian

Unknown

Race/ethnicity of the infant (check all that apply)

American Indian / Alaska Native

Asian

Black / African American

Multi-Racial / Other Race Unknown

Native Hawaiian / Other Pacific Islander

Hispanic / Latino

White / Caucasian

Unknown

Age of infant (in days)

Gender of infant

Male

Female

Zip code for where the infant will reside

Zip code for birthing individual

County the infant will reside in Value is not selected

Did the hospital develop a Family Care Plan with the family?

Yes

No

Who developed the plan? Value is not selected

Define "Other":

When was the Family Care Plan completed?

Why was the hospital unable to develop a Family Care Plan with the family? Value is not selected

Define "Other":

Was the family linked to appropriate services?

Yes

No

Does the family have a need for services and supports, including the infant, birthing individual, and caregivers?

Yes

No

Date of notification completion date

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Imported: NJ Family Care (POSC) Data Collection Form

Healthcare Provider Information

Information about the Infant

Infant Demographics