New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 32 - ADVANCE DIRECTIVES FOR MENTAL HEALTH CARE
Appendix B

Registration

I hereby submit my mental health advance directive to the Division of Mental Health and Addiction Services in the

New Jersey Department of Human Services to be registered. I choose the following password that will permit access for me and anyone with whom I share it.

__________________________________

I further understand that a licensed health care provider who is providing me with mental health care may be able to access my directive if needed. No other person will be permitted to see the directive (except as required for administration of the registry) without my permission.

___________________________________

Signature

Print Name: _________________________ , contact information for confirmation:

___________________________________

Witness:

____________________________________

Dated: ______________________________

Send original to: NJDMHAS Registry, 222 S. Warren Street, PO Box 700, Trenton, NJ 08625-0700 and attach a copy of your entire mental health care advance directive. You may also submit other documents to be registered that affect your legal ability to consent, such as a health care advance directive, durable power of attorney, temporary or limited guardianship orders, etc., which the registry will accept in its discretion.