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New Jersey CN 12012: Physician or Psychologist Cert

In New Jersey, a complaint asking the Superior Court, Chancery Division, Probate Part, to declare a person incapacitated and appoint a guardian is supported by CN 12012 certifications. A clinician meets it when the petitioner or their attorney asks for an evaluation of the alleged incapacitated person. The certification records the examination, diagnosis, prognosis and the decision-making areas where the person does or does not retain capacity.

Who completes it

The filing attorney or self-represented litigant fills in the caption. A physician (MD or DO) or psychologist (PhD or PsyD), or a Division of Developmental Disabilities employee authorized to do psychological evaluations, completes the certification items and signs.

Submitting and payment

How to submit it
The signed certification goes back to the petitioner or their attorney, who files it with the verified complaint in the Superior Court, Chancery Division, Probate Part, where it is kept confidential.

Good to know

  • Court rule R. 4:86-2 generally requires two such certifications; one may come from a Division of Developmental Disabilities psychologist.
  • The examiner can find the person unfit in all areas, or in some areas while retaining capacity for medical, legal, residential, educational, vocational, financial or other decisions.
  • The examiner must state whether the person can attend the court hearing and, if not, why.
  • The examiner certifies no family relationship, no role in or financial interest in the proposed care institution, and agrees to supplement the form if new information arises.

Get the official form

Download the current version from the source each time; forms change without notice.

Certification of Physician or Psychologist

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is the New Jersey CN 12012 a public document?

No. The form carries a notice that it is not a public document and that the information entered will be kept confidential, which is why it asks for full identifying details. It is filed with the guardianship complaint in the Chancery Division, Probate Part.

Who can sign the CN 12012?

A licensed physician (MD or DO) or psychologist (PhD or PsyD) who examined the alleged incapacitated person, or a Division of Developmental Disabilities employee authorized to conduct psychological evaluations. The signer notes whether they treat the person or examined them only to evaluate capacity.

Can the CN 12012 support a limited guardianship?

Yes. Instead of finding the person unfit in all areas, the examiner can mark the areas where the person still has capacity, such as medical, residential or financial decisions, and then explain the factual basis for that opinion, along with the diagnosis and prognosis, in item 10.