Language
English (US)
Español
User Enrollment Form
Agency Representatives are required to use this form to enroll all Users.
Before you begin...
Verify
User meets
NJEIS Personnel Standards
for requested role/specialty.
Obtain
Code of Conduct/E-Signature Verification form signed by User. Please visit the
NJ EIMS homepage
to access the form.
Collect
User demographic information required for this form.
Create
a single New Jersey User Enrollment PDF packet containing all required documentation for requested role/specialty (incomplete submissions will not be processed).
Save
the PDF packet as (
UserLegalName_AgencyName
). It will be uploaded during this online process.
Complete
the following information to enroll the User.
Agency Category
*
EIP - Early Intervention Program
REIC - Regional Early Intervention Cooperative
SCU - Service Coordination Unit
SPOE - System Point of Entry
STATE - State Office
EIP
Select One
EIP: AHS Hospital Corp
EIP: Archway Programs, Inc. dba Step-By-Step
EIP: Bergen County Special Services School District
EIP: Big Apple Therapy Associates LLC
EIP: Catholic Family & Community Services
EIP: Cerebral Palsy League Inc dba Kaleidoscope
EIP: Children's Specialized Hospital
EIP: Classic Rehabilitation, LTD
EIP: Community Healthcare Systems, LLC
EIP: Compcare Therapeutics Inc
EIP: Eden Autism Services, Inc.
EIP: Family Resource Associates, Inc.
EIP: Gloucester County Special Services School District
EIP: Hudson Milestones
EIP: Hunterdon Medical Center
EIP: Innovative Interventions
EIP: Innovative Therapeutic Services, LLC
EIP: Inspira Medical Centers, Inc.
EIP: JFK HS Community Hospital Group T/A JRI Physical Medicine
EIP: Kid Clan Services, Inc.
EIP: Ladacin Network, Inc.
EIP: Lee's Developmental Services LLC
EIP: Montclair State University
EIP: Mountain Lakes Board of Education
EIP: NJ Institute for Disabilities aka The Children's Center
EIP: P.G. Chambers School
EIP: Pediatric Therapy Resources, LLC
EIP: Pillar Care Continuum, Inc.
EIP: Progressive Steps, LLC
EIP: Rowan University
EIP: Rutgers, The State University of New Jersey, RBHS NJ Med
EIP: S & S Therapeutics, Inc.
EIP: Salem County Special Services School District
EIP: School for Children with Hidden Intelligence
EIP: Shirley Eves Developmental & Therapeutic Center, Inc.
EIP: St. Joseph's School for the Blind
EIP: St. Joseph's Hospital & Medical Center
EIP: Summit Speech School
EIP: Sunny Days Early Childhood Developmental Services, Inc.
EIP: The Arc of Bergen & Passaic Counties, Inc.
EIP: The Arc of Essex County Inc.
EIP: The Arc of Somerset County
EIP: The Arc of Union County, Inc.
EIP: The Arc/Warren County Chapter
EIP: TheraCare
EIP: TheraNorth Services, LLC
EIP: Therapy Associates LLC
EIP: Virtua Health System
EIP: Vista Rehab Services
Select the EIP
REIC
Select One
REIC: Family Link
REIC: Mid-Jersey
REIC: Northeast
REIC: Southern New Jersey
Select the REIC
SCU
Select One
SCU: Bergen County Department of Human Services (Bergen)
SCU: Catholic Family & Community Services (Passaic)
SCU: Central Jersey Family Health Consortium Inc. (Mercer)
SCU: Children's Specialized Hospital (Hudson)
SCU: Children's Specialized Hospital (Middlesex, Somerset, Union)
SCU: DAWN Center for Independent Living, Inc. (Morris, Sussex)
SCU: Essex County Department of Health & Rehabilitation (Essex)
SCU: Hunterdon Medical Center (Hunterdon)
SCU: Ocean County Department of Health (Ocean)
SCU: Southern NJ Perinatal Cooperative (Atlantic, Camden, Cape May, Cumberland, Gloucester, Salem)
SCU: The Arc/Warren County Chapter, Inc. (Warren)
SCU: Visiting Nurse Association of Central Jersey (Burlington, Monmouth)
Select the SCU
SPOE
Select One
SPOE: Family Link
SPOE: Mid-Jersey
SPOE: Northeast (Helpful Hands)
SPOE: Southern New Jersey
Select the SPOE
User's Date of Birth
*
/
Month
/
Day
Year
Date
User's Date of Birth Verification
*
/
Month
/
Day
Year
Date
User's Work E-mail
*
Verify User's Work Email
example@example.com
User's Work Phone Number
*
User's Full Legal Name
*
First
Middle
Last
Maiden/Other/AKA
USER's Security Word (must be unique per user)
*
This word is required so the Help Desk can provide you with efficient and secure account assistance. EVERY PROVDER must have a UNIQUE account security word. This word should be treated like a password and should not contain the user's name.
User's Access Type
*
EIP with Caseload Only
EIP Admin
EIP (View)
SCU Admin
Ongoing Service Coordinator
SCU (View)
SPOE Admin
SPOE Service Coordinator (Edit)
SPOE (View / Some Edit)
REIC Admin
REIC Admin (Edit)
REIC Admin (View)
State Admin Superuser
State Admin (Edit)
State Admin (View)
TET status must be approved by the state
User's Specialty
*
Not Applicable
Audiologist
Behavioral Specialist
Child Development Associate
Child Development Specialist
Family Therapist
Foreign Language Interpreter/Translator
Interpreter for the Deaf
Nurse (Registered)
Nutritionist
Occupational Therapist
Occupational Therapy Asst. (COTA)
Opthamologist
Optometrist
Orientation/Mobility Specialist
Physical Therapist
Physical Therapy Asst. (PTA)
Physician
Psychologist
Service Coordinator
Service Coordinator Associate
Social Worker
Special Educator
Special Educator-Hearing Impaired
Special Educator-Visually Impaired
Speech-Language Pathologist
License Number (if applicable)
License Effective Date (if applicable)
/
Month
/
Day
Year
License Expiration Date (if applicable)
/
Month
/
Day
Year
EIP Admin
TET Coordinator (limited to 1)
EIP Coordinator (limited to 1)
TET Supervisor
EIP Supervisor
EIP (View)
EIP Administrative Staff (including Data & Financial)
SCU Admin
SCU Coordinator (limited to 1)
Service Coordinator Supervisor
Ongoing Service Coordinator
Ongoing Service Coordinator
SCU (View)
SCU Administrative Staff
Ongoing SC Associate
SPOE Admin
SPOE SC Manager (limited to 1)
SPOE SC Supervisor (limited to 1)
SPOE Service Coordinator (Edit)
SPOE SC
SPOE (View / Some Edit)
SPOE Administrative Assistant
Ring Central
REIC Admin
REIC Data Manager (limited to 1)
REIC Data Supervisor (limited to 1)
REIC Admin (Edit)
REIC Data Entry FCP
REIC Admin (View)
REIC Director (limited to 1)
T & TA Coordinator
Family Support Coordinator
REIC Administrative Assistant
State Admin (Superuser)
Part C Coordinator
Data Manager
EIMS Project Specialist
State Admin (Edit)
Results Accountability Coordinator
FCP Coordinator
Procedural Safeguards Coordinator
Monitoring Coordinator
CMO / Data Staff
State Admin (View)
Monitoring Supervisor / Team
T & TA Coordinator
NJEIS Project Specialist
Secretary / Clerk
Grants Program Officer
New Jersey User Enrollment Documents Included
*
Code of Conduct & Electronic Signature Agreement (required)
Background Check (required)
Resume (if applicable)
Transcript(s) (if applicable)
Professional License(s) or Teaching Certificate(s) (if applicable)
Procedural Safeguards Module Certificate (if applicable)
New Jersey User Enrollment Documentation Packet Upload
*
Assurances
*
I have reviewed the enrollment application and credentials of the above practitioner.
I have verified the practitioner meets the NJEIS Personnel Standards for the selected role.
I am authorized by my agency to submit practitioner application materials.
I understand that, by typing my full name in the box below, I am electronically signing this document.
Agency Representative Name
*
First Name
Last Name
Agency Representative Email
*
example@example.com
Does this new enrollee require impersonation rights?
No
Yes
Save
Submit Form
Should be Empty: