JV-219-INFO Information About Psychotropic Medication Forms Use the Judicial Council forms listed below when requesting an order regarding psychotropic medication. Local forms may be used to provide additional information to the court. JV-220, Application Regarding Psychotropic Medication JV-220(A), Prescribing Physician’s Statement—Attachment JV-221, Proof of Notice: Application Regarding Psychotropic Medication JV-222, Opposition to Application Regarding Psychotropic Medication JV-223, Order Regarding Application for Psychotropic Medication General Instructions 1 Use psychotropic medication forms when a child is under the jurisdiction of the juvenile court and living in an out-of-home placement and the child’s physician is asking for an order: a. giving permission for the child to receive a psychotropic medication that is not currently authorized or b. renewing an order for a psychotropic medication that was previously authorized for the child because the order is due to expire. 2 Use of the forms is mandatory for a child who is a dependent of the juvenile court and living in an out-of-home placement. 3 Use of the forms is mandatory for a child who is a ward of the juvenile court and living in a foster care placement, as defined in Welfare and Institutions Code section 727.4. 4 Use of the forms is optional for a child who is a ward of the juvenile court and living in an out-of-home facility that is not considered a foster care placement as defined in Welfare and Institutions Code section 727.4, unless use of the forms is required by a local rule of court. 5 Use of the forms is not required if the court has previously entered an order giving the child’s parent the authority to approve or deny the administration of psychotropic medication to the child. 6 Form JV-220(A), Prescribing Physician’s Statement—Attachment, must be completed and signed by the prescribing physician and forwarded to the person responsible for completing form JV-220, Application Regarding Psychotropic Medication, as provided for in local court rules or local practice protocols. The completed JV-220(A), with all its attachments, must be attached to JV-220 when it is filed with the court. 7 The person or persons responsible for providing notice under local court rules or local practice protocols must complete, sign, and file with the court form JV-221, Proof of Notice: Application Regarding Psychotropic Medication. JV-220, Application Regarding Psychotropic Medication 1 This form gives the court basic information about where the child lives and whether the current situation has caused the child to be moved to a temporary location such as a psychiatric hospital, a juvenile hall, a shelter home, or respite care. It also provides the name and contact information for the child’s social worker or probation officer. 2 This form may be completed by the prescribing physician, the medical office staff, the child welfare services staff, the probation department staff, or the child’s caregiver. If completed by a staff person from the medical office, the child welfare services agency, the probation department, or the child’s caregiver, he or she must check the appropriate box, type or print his or her name, and sign the form. If completed by the prescribing physician, he or she must check the appropriate box and complete and sign JV-220(A). Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2009 Welfare and Institutions Code, §§ 369.5, 739.5 California Rules of Court, rule 5.640 Information About Psychotropic Medication Forms JV-219-INFO, Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com JV-219-INFO Information About Psychotropic Medication Forms JV-220(A), Prescribing Physician's Statement—Attachment 1 This form must be completed and signed by the prescribing physician, who must provide information related to the administration of the psychotropic medication, including the child’s diagnosis, relevant medical history, other therapeutic services, the psychotropic medication to be administered, and the basis for the psychotropic medication recommendation. 2 Prior court authorization must be obtained before a psychotropic medication not currently authorized is given to a child except in an emergency situation. An emergency situation occurs when a physician finds that the child requires psychotropic medication because of a mental condition and the purpose of the medication is to protect the life of the child or others, prevent serious harm to the child or others, or to treat current or imminent substantial suffering and it is impractical to obtain prior authorization from the court. Court authorization must be sought as soon as practical but never more than two court days after the emergency administration of the psychotropic medication. JV-221, Proof of Notice: Application Regarding Psychotropic Medication 1 This form provides verification of the notice required by rule 5.640 of the California Rules of Court. 2 This form must be completed and signed by the person or persons responsible for providing notice as required by local court rules or local practice protocols. A separate signature line is provided on each page of the form to accommodate those courts in which the provision of notice is shared between agencies—for example, when local court rule or local practice protocol requires the child welfare services agency to provide notice to the parent or legal guardian and the caregiver and the juvenile court clerk’s office to provide notice to the attorneys and CASA volunteer. If one agency does all the required noticing, only one signature is required on page 2 of the form. JV-222, Opposition to Application Regarding Psychotropic Medication 1 This form must be used when the parent or guardian, the attorney of record for a parent or guardian, the child, the child’s attorney, or the child’s CAPTA guardian ad litem does not agree that the child should take the recommended psychotropic medication. 2 Within two court days of receiving notice of the application regarding psychotropic medication, the parent or guardian, his or her attorney, the child, the child’s attorney, or the child’s CAPTA guardian ad litem who disagrees must complete, sign, and file form JV-222 with the clerk of the juvenile court. 3 The court will make a decision about the child’s psychotropic medication after reading the application and its attachments and any opposition filed on time. The court is not required to set a hearing when an opposition is filed. If the court does set the matter for a hearing, the juvenile court clerk must provide notice of the date, time, and location of the hearing to the parents or legal guardians, their attorneys, the child if 12 years of age or older, the child’s attorney, the child’s current caregiver, the child’s social worker, and the social worker’s attorney at least two court days before the date set for the hearing. In delinquency matters, the clerk also must provide notice to the child regardless of his or her age, the child’s probation officer, and the district attorney. JV-223, Order Regarding Application for Psychotropic Medication This form contains the court’s findings and orders about psychotropic medications. Rev. January 1, 2009 Information About Psychotropic Medication Forms JV-219-INFO, Page 2 of 2