JV-221 Proof of Notice: Application Regarding Psychotropic Medication Clerk stamps date here when form is filed. Read JV-219-INFO, Information About Psychotropic Medication Forms, for more information about the required forms and the application process. a.1 The following parents/legal guardians of the child were given notice of the physician’s request to begin and/or to continue administering psychotropic medication, the name of each medication, and that a JV-220, Application Regarding Psychotropic Medication, and a JV-220(A), Prescribing Physician’s Statement—Attachment, are pending before the court. They were also provided with JV-219-INFO, Information About Psychotropic Medication Forms, and a blank copy Fill in court name and street address: of JV-222, Opposition to Application Regarding Psychotropic Superior Court of California, County of Medication, or with information on how to obtain a copy of each form. a. Name: Date notified: Relationship to child: Manner: In person By phone at (specify): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): b. Name: Date notified: Fill in child's name and date of birth: Child's Name: Date of Birth: Fill in case number when form is filed. Case Number: Relationship to child: By phone at (specify): Manner: In person By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): c. Name: Date notified: Relationship to child: Manner: 2 3 By phone at (specify): In person By depositing the required information and a copy of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): Parental rights were terminated, and the child has no legal parents who must be informed. 5 Parent/legal guardian (name): was not informed because (state reason): Parent/legal guardian (name): was not informed because (state reason): The child’s current caregiver was notified that a physician is asking to treat the child with psychotropic medication and that a JV-220 and a JV-220(A) are pending before the court as follows: Caregiver (name): Manner: By phone at (specify): In person By depositing the required information in a sealed envelope in the United States mail, with first-class postage prepaid, to the following address (specify): 6 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. 4 Date: Type or print name 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 Signature Proof of Notice: Application Regarding Psychotropic Medication Signature follows on page 2. JV-221, Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case Number: Child's name: 7 The child’s attorney and the child's CAPTA guardian ad litem, if that person is someone other than the child's attorney, were provided with completed Forms JV-220, Application Regarding Psychotropic Medication, and JV-220(A), Prescribing Physician's Statement—Attachment; a copy of JV-219-INFO, Information About Psychotropic Medication Forms; and a blank copy of JV-222, Opposition to Application Regarding Psychotropic Medication, as follows: Date notified: a. Attorney’s name: Manner: In person By fax at (specify): By depositing copies in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): b. CAPTA guardian ad litem’s name: Date notified: Manner: In person By fax at (specify): By depositing copies in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): 8 The following attorneys were given notice of the physician’s request to begin and/or continue administering psychotropic medication, the medication name, and that a JV-220, Application Regarding Psychotropic Medication and a JV-220(A), Prescribing Physician's Statement—Attachment, are pending before the court. They were also provided with a copy of JV-219-INFO, Information About Psychotropic Medication Forms, and a blank copy of JV-222, Opposition to Application Regarding Psychotropic Medication, or with information on how to obtain a copy of each form, as follows: Date notified: a. Attorney’s name: Attorney for (name): Manner: In person By phone at (specify): By fax at (specify): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): Date notified: b. Attorney’s name: Attorney for (name): Manner: By fax at (specify): In person By phone at (specify): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): Date notified: c. Attorney’s name: Attorney for (name): By phone at (specify): In person Manner: By fax at (specify): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): 9 The child’s CASA volunteer was notified that a JV-220 and a JV-220(A) are pending before the court as follows: Date notified: CASA volunteer (name): Manner: In person By phone at (specify): By depositing the required information in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Type or print name New. January 1, 2008 Signature Proof of Notice: Application Regarding Psychotropic Medication JV-221, Page 2 of 2