Clerk stamps date here when form is filed. JV-218 Child's Opinion About the Medicine You may use this form to tell the judge what you think about the medicine that a doctor wants you to take. You do not have to use this form if you do not want to. There are other ways to tell the judge how you feel. You can: · · Talk to the judge at a hearing or write the judge a letter, or Ask your lawyer, social worker, probation officer, or CASA to tell the judge how you feel. Fill in court name and street address: Superior Court of California, County of You may ask someone you trust to help you read and fill out this form. And you may add as many pages as you need. If you add extra pages, please put your name and the number of the question you are answering on each extra page. 1 Your name: (first) (middle) (last) Fill in child's name and date of birth: Child's Name Date of Birth: Court fills in case number when form is filed. 2 Your date of birth: (month) (day) (year) Case Number: Answer these questions about this medicine: 3 4 5 6 Do you know that a doctor wants you to take a medicine? Do you know the name and dose of the medicine the doctor wants you to take? Have you taken this medicine before? Do you want more information before you decide if you want to take it? If yes, what do you want to know? Yes Yes Yes Yes No No No No Not sure Not sure Not sure 7 8 Did anyone tell you how the medicine is supposed to help you? Did anyone explain the possible side effects? If yes, what did they say? Yes Yes No No Not sure Not sure 9 What is your opinion about taking the medicine? Judicial Council of California, www.courts.ca.gov New July 1, 2016, Optional Form Welfare and Institutions Code, § 369.5 California Rules of Court, rule 5.640 Child's Opinion About the Medicine JV-218, Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Child's name: 10 Do you agree to take the medicine? Explain your answer here, if you want to: Yes No Not sure Questions about you 11 List any other treatment or therapy you are doing now: Individual talk therapy None Counseling at school Group talk therapy Cognitive Behavioral Therapy (CBT or practicing behaviors) Other (list any other treatment here): Family therapy Art or play therapy 12 What do you like to do for fun? 13 What activities would you like to be involved in now? 14 Say anything else about yourself or the medicine that you want the judge to know. For a 17-Year Old Youth ONLY If you are under 17, skip to the next question. 15 When you turn 18, a. Will you be able to keep the doctor you have now? b. Will you know how to get this medicine if you want to keep taking it? Yes Yes No No Not sure Not sure New July 1, 2016 Child's Opinion About the Medicine JV-218, Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Child's name: For a child taking this medicine now If you are NOT taking this medicine now, skip to the next question. 16 Do you have any side effects from the medicine? If Yes, check below: Weight gain Problems sleeping Weight loss Feeling very sleepy Headache Nausea Yes No Constipation Feel dizzy Other (list any other side effects here): 17 I you have side effects, did you tell your doctor? If Yes, your doctor's name: 18 Did someone help you with this form? If Yes, who? my social worker Other (explain): Yes No Yes my probation officer my caregiver No my lawyer my CASA Check here if you are going to add extra pages to this form. And say how many pages: Date: Type or print child's name Child signs here Type or print name of other person who helped child fill out form Helper signs here New July 1, 2016 Child's Opinion About the Medicine JV-218, Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com