JV-220(A) Case Number: Prescribing Physician's Statement—Attachment This form must be completed and signed by the prescribing physician. Read JV-219-INFO, Information About Psychotropic Medication Forms, for more information about the required forms and the application process. 1 2 Information about the child (name): Date of birth: Current height: Gender: Ethnicity: Type of request: a. An initial request to administer psychotropic medication to this child b. A request to continue psychotropic medication the child is currently taking 1 3 4 Current weight: This application is made during an emergency situation. The emergency circumstances requiring the temporary administration of psychotropic medication pending the court’s decision on this application are: Prescribing physician: a. Name: b. Address: c. Phone numbers: License number: d. Medical specialty of prescribing physician: Child/adolescent psychiatry General psychiatry Family practice/GP Pediatrics Other (specify): 5 This request is based on a face-to-face clinical evaluation of the child by: a. the prescribing physician on (date): b. 6 7 other (provide name, professional status, and date of evaluation): Information about child provided to the prescribing physician by (check all that apply): caregiver teacher social worker probation officer child records (specify): other (specify): parent Describe the child’s symptoms, including duration as well as the child’s response to any current psychotropic medication. If the child is not currently taking psychotropic medication, describe treatment alternatives to the proposed administration of psychotropic medication that have been tried with the child in the last six months. If no alternatives have been tried, explain the reasons for not doing so. Judicial Council of California, www.courtinfo.ca.gov New January 1, 2008, Mandatory Form Welfare and Institutions Code, § 369.5 California Rules of Court, rule 5.640 Prescribing Physician's Statement—Attachment JV-220(A), Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case Number: Child's name: 8 Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (provide full Axis I and Axis II diagnoses; inclusion of numeric codes is optional): 9 Therapeutic services, other than medication, in which the child will participate during the next six months (check all that apply; include frequency for group therapy and individual therapy): a. Individual therapy: b. Group therapy: c. d. 10 Milieu therapy (explain): Other modality (explain): a. Relevant medical history (describe, specifying significant medical conditions, all current nonpsychotropic medications, date of last physical examination, and any recent abnormal laboratory results): b. Relevant laboratory tests performed or ordered (optional information; provide if required by local court rule): kidney function liver function thyroid function UA glucose lipid panel medication blood levels (specify): pregnancy EKG CBC other (specify): 11 Mandatory Information Attached: Significant side effects, warnings/contraindications, drug interactions (including those with continuing psychotropic medication and all nonpsychotropic medication currently taken by the child), and withdrawal symptoms for each recommended medication are included in the attached material. 12 a. b. The child was told in an age–appropriate manner about the recommended medications, the anticipated benefits, the possible side effects and that a request to the court for permission to begin and/or continue the medication will be made and that he or she may oppose the request. The child’s response was agreeable other (explain): The child has not been informed of this request, the recommended medications, their anticipated benefits, and their possible adverse reactions because: (1) the child is too young. the child lacks the capacity to provide a response (explain): (2) (3) other (explain): 13 The child’s present caregiver was informed of this request, the recommended medications, the anticipated benefits, and the possible adverse reactions. The caregiver’s response was agreeable other (explain): 14 Additional information regarding medication treatment plan: New January 1, 2008 Prescribing Physician's Statement—Attachment JV-220(A), Page 2 of 3 Case Number: Child's name: 15 List all psychotropic medications currently administered that you propose to continue and all psychotropic medications you propose to begin administering. Mark each psychotropic medication as New (N) or Continuing (C). Administration schedule is optional information; provide if required by local court rule. Medication name (generic or brand) and symptoms targeted by each medication’s anticipated benefit to child C or N Maximum total mg/day Treatment duration* Administration schedule (optional) • Initial and target schedule for new medication • Current schedule for continuing medication • Provide mg/dose and # of doses/day • If PRN, provide conditions and parameters for use Med: Targets: Med: Targets: Med: Targets: Med: Targets: Med: Targets: *Authorization to administer the medication is limited to this time frame or six months from the date the order is issued, whichever occurs first. 16 List all psychotropic medications currently administered that will be stopped if this application is granted. Medication name (generic or brand) Reason for stopping 17 List the psychotropic medications that you know were taken by the child in the past and the reason or reasons these were stopped if the reasons are known to you. Medication name (generic or brand) Reason for stopping Date: Type or print name of prescribing physician New January 1, 2008 Signature of prescribing physician Prescribing Physician's Statement—Attachment JV-220(A), Page 3 of 3