For Court Use Only « SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES » Psychotropic Medication Authorization Form LOG # THIS FORM MUST BE FAXED TO THE PROPER LOCATION BELOW TO OBTAIN COURT AUTHORIZATION PRIOR TO THE ADMINISTRATION OF PSYCHOTROPIC MEDICATION, ABSENT AN EMERGENCY . D EPENDENCY : FAX: (562) 941-7205 D ELINQUENCY : FAX: ( 323) 441-1110 A. IDENTIFYING INFORMATION OR ( 323) 441-1120 Please include this form with discharge packet! Child’s Name (Last, First, MI) Sex D.O.B. Child’s Current Placement Name and Address Ethnicity Ct. Dept. Phone Court Case No. Plcmt. Contact Person Fax Relative Foster Home Group Home Placement Type B.J. Nidorf Juv. Hall Central Juv. Hall Los Padrinos Juv. Hall Facility: Probation Camp State Hospital County Jail Dorothy Kirby Center Developmental Center Other Acute Hospital Name: Phone Address: Hosp. Contact Person Fax CSW/DPO: Name: Region/Office: Phone: Name of Prescribing Physician (print) Specialty: Gen./Family Practice License No. Pediatrics Neuro. Child/Adolesc.Psychiatry Gen.Psych. Other: Address: Office Phone: Emergency Phone: SECTIONS B & C ON PAGES 1&2 Fax: MUST BE PERSONALLY COMPLETED AND SIGNED BY THE PRESCRIBING PHYSICIAN. B. CLINICAL INFORMATION B1. Date child last seen by physician: B2. Information about child from: Who brought child/what is relationship? child- caregiver- teacher- records- other Present illness d uration: B3. Diagnosis: (DSM IV Dx & Codes required) B4. Current therapeutic services other than medication (specify type, frequency, location): B5. Last Physical Exam (Minor must have had physical exam during the 12 months prior to starting psychotropic medication and then yearly.) Date of PE: Location of PE records: Current Height: Weight: Date Measured: Significant Medical Problems or Lab Test, BP or Pulse Abnormalities: No Yes Non-psychotropic prescribed medications taken regularly: No Yes B6. Indicate relevant laboratory tests performed or ordered. No lab work done/ordered CBC UA Liver Function Thyroid Function Medication Blood Level (specify): Kidney Function } If Yes, describe below or attach information. Glucose Lipid Panel Electrolytes EKG Other: B7. Current Psychotropic medication request is: Continuation of Rx Only Non-emergency Emergency Nature and circumstances of emergency must be specified here to allow for temporary administration pending judicial order: (Administration of Continued medication or Emergency medication may proceed immediately upon submission of form.) Psychotropic Medication Authorization Form (PMAF) 10-24-05 American LegalNet, Inc. www.USCourtForms.com Page 1 of 3 Child’s Name (Last, First, MI) LOG # C. MEDICATIONS (List all psychotropic medications now being taken or to be taken when authorized or being discontinued.) Mark them N ew-C ontinued-D iscontinued (with respect to the child not the prescribing physician) (Use additional sheet if needed.) Indicate if cross titrating medications. If use of a medication is to be short-term (less than 6 months), specify time frame. C1. N NAME OF MEDICATION (S) or C AND or TARGET SYMPTOMS FOR EACH D ADMINISTRATION SCHEDULE • • • • Indicate Initial and Target Schedules for New Rx Indicate Current Schedule for Continued Rx Indicate mg/dose and # of doses/day If PRN, specify conditions & parameters of use M AXIMUM TOTAL DOSE/DAY Med: Targets: Med: Targets: Med: Targets: Med: Targets: Med: Targets: Med: Targets: C2. Indicate response to ongoing Rx treatment and reasons for any Rx changes (with respect to target symptoms &/or adverse effects): C3. Prior medications: C4. (Completion of C4 a. or b. is required.) a. Child has been informed of the proposed medication treatment, anticipated benefits and potential adverse effects. Child is b. (Complete C5 and/or C6 if they are applicable.) agreeable to opposed to the proposed treatment. (Child’s own written statement may be attached.) Child has not been informed because the child is too young and/or lacks the capacity to understand the treatment or provide a response. C5. Child’s current Foster Parent or Relative Care taker has been informed of the proposed medication treatment, anticipated benefits and potential adverse effects. Foster parent or Relative Caretaker is agreeable to opposed to the proposed treatment (Use additional sheet if needed.) C6. Child’s Parent or Legal Guardian (circle one) will not or cannot consent to the proposed treatment. Additional explanation (Use additional sheet if needed.): I hereby declare that all the foregoing is true to the best of my knowledge. Prescribing Physician’s Signature Psychotropic Medication Authorization Form (PMAF) 10-24-05 Date American LegalNet, Inc. www.USCourtForms.com Page 2 of 3 Child’s Name (Last, First, MI) LOG # D. NOTICE • Parent/Guardian Notice sent on: Notifying Agency: Probation DCFS Date By: Print Name Sign If not sent, reason: • Child’s Attorney Notice sent by Court on: Date By: Print Name Sign If not sent, reason: E. JCMHS REVIEW This form has been reviewed by staff of Juvenile Court Mental Health Services. This review is intended to give the court general information regarding the appropriateness of the psychotropic medication treatment for which authorization is requested given the clinical information indicated on the form (age, diagnosis, symptoms, etc.). See attached JCMHS review page for further information. F. COURT ORDER (to be completed by the court) Court having read and considered the above request: • • The matter is set for a hearing within five court days on (date): at (time): in department: The application for authorization to administer psychotropic medication is a) Granted as requested b) Denied (specify reason for denial): c) Granted with the following modifications or conditions (specify): • This order for authorization is effective until terminated or modified by court order or until 180 days from this order, whichever is earlier. If the prescribing physician named above is no longer treating the child, the authorization may extend to physicians who subsequently treat the child. Except in an emergency situation, an increase in the dosage beyond the approved maximum daily dosage or a change in or the addition of other medications requires the treating physician to submit a new application. A change in the child’s placement does not require a new order for psychotropic medication, and this authorization, if it is still in effect, must accompany the child if placement is changed. • Notice Requirements a) The notice requirements have been met. b) The notice requirements have NOT been met. Proper notice was not given to: Date: Print Name Sign Judicial Officer of the Juvenile Court Psychotropic Medication Authorization Form (PMAF) 10-24-05 American LegalNet, Inc. www.USCourtForms.com Page 3 of 3