New Jersey Judiciary form CN 10753. This walkthrough fills the
59 text fields; 11 checkbox(es) on the form are
left for you to mark after download.
This page covers the form headed “Application to the Recovery Court Program,” control number CN 10753. Its footer reads “Revised 01/01/2020, Drug Court name changed to Recovery Court - January 2022, CN 10753,” and every page carries the line “This form is to be used for Adult Recovery Court cases.” The document runs four pages. The application pages are headed Superior Court of New Jersey, Office of Probation Services, with a blank for Vicinage.
The first two pages gather applicant and case information: date of application, checkboxes asking whether disability accommodations are needed and whether an interpreter will be needed, each with a space for the request or the language, then name, alias, race, sex, date of birth, Social Security Number, current address with city, state, zip and how long at that address, previous address, county, telephone number with extension, and cell phone number, plus next of kin with relationship and telephone. Yes/no checkboxes ask whether the applicant is an Armed Forces veteran, is currently involved with DCP&P, is presently incarcerated, and is on probation or on parole, alongside spaces for a co-habitant and relationship, a jail number, an SBI number, and a probation/parole officer’s name. Case fields cover current charges, county, indictment number, PG number, and next court event with date and judge; the form also asks whether the applicant has ever been sentenced to recovery court before, with the name of that court and when, and whether matters are pending in any other court, with that court’s name, charges, next court event, date, judge, detainers, and jurisdictions. Signature and date lines appear for a defense attorney, whose name and telephone number are also collected, and for the applicant.
Pages three and four are a separate “Records Release Authorization (Recovery Court Involvement)” headed Recovery Court Program, Superior Court of New Jersey, Treatment Assessment Services for the Courts. In it a named client authorizes the Treatment Assessment Services for the Courts substance abuse evaluator, “the State of New Jersey Recovery Court Team (to include the Judge, defense attorney, prosecutor, Recovery probation officers, treatment representatives, and other Recovery team members),” and treatment providers “to be added once known” to communicate and disclose to one another information such as TASC evaluation results, involvement and requirements of the Recovery Court/Superior Court mandate, pertinent medical or psychological information, and drug/alcohol screen or test results. Each treatment-provider slot repeats lines for the program’s name and address, “(Date Amended),” “(Client’s initials)” and “(Witness’ Initials).” The stated purpose of the disclosure is to monitor compliance with conditions of the Recovery Court/Superior Court mandate. For non-criminal matters (juvenile and family), the form makes the consent “subject to revocation at any time except to the extent that action has been taken in reliance thereon,” with a blank for the date, event or condition on which it otherwise expires. For adult criminal cases, the form states, the consent “cannot be revoked but will remain in effect until there has been a formal and effective termination of my involvement with the Recovery Court Program.”
Client and witness signature and date lines follow, and page four closes with a federal-confidentiality notice. That notice states the information comes from records protected by federal confidentiality rules at 42 CFR Part 2, that those rules prohibit any further disclosure of information in the record identifying a patient as having or having had a substance use disorder unless the disclosure is expressly permitted by the written consent of the individual whose information is disclosed or otherwise permitted by Part 2, that a general authorization for release of medical or other information is not sufficient for that purpose (citing section 2.31), and that the federal rules restrict use of the information to investigate or prosecute a patient with a substance use disorder with regard to a crime, except as provided at sections 2.12(c)(5) and 2.65.
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How this works & your privacy
⏱ This is a long form — about 59 questions. Set aside about 5
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⬇ Blank form in English (PDF) — The English form as published, blank, for printing and filling by hand.
⬇ Este formulario en español (PDF) — la versión oficial en español publicada por el Poder Judicial de Nueva Jersey.
This form in Spanish, as published by the New Jersey Judiciary.