SUPERIOR COURT OF SACRAMENTO COUNTY OF SACRAMENTO SITTING AS THE JUVENILE COURT In the matter of Case No. A minor PHYSICIAN'S DECLARATION RE: PSYCHOTROPIC MEDICATION Date of Birth: Absent parental/legal guardian consent, the Sacramento County Juvenile Court must authorize the non-eme administration of any psychotropic medication for a dependent minor of the Court prior to the administration of the medication. Please be advised that neither foster parents nor social workers are authorized to consent to the administration of psychotropic medications. This Declaration and any attachments must be typed and completed with as much detailed information as possible. You may attach any clinical information which clarifies the treatment plan. Your signed Declaration should be submitted to the Department of Health and Human Services social worker assigned to the minor's case. BACKGROUND INFORMATION Minor's sex: Male Female Minor's weight: Medical allergies: Date of last physical exam, where, and by whom Date of last Lab work (type and results of abnormalities) MEDICAL INFORMATION 1. Diagnosis: AXIS I: AXIS II: AXIS III: 2. List medication to be prescribed/strength/dosage: Medication Strength Dosage 3. Expected duration of trial on this medication: JV-SC7 In re: 05/15/00 Case No Pap 1 ot 4 Pages 2002 © American LegalNet, Inc. 4. I will be ordering the minor to have the following lab work and will be seeing the minor on a repeated schedule as follows: 5. Common side effects of requested medication: 6. Prognosis: 7. Target symptom(s) for the medication being requested: 8. Is minor presently on any other medication? Yes No If yes, list: If yes, will previous course of medication continue? Yes No If yes, what side effects are to be expected with this combination of medication: If applicable, explain why more than one psychotropic medication is necessary: 9. Risks involved in the treatment: 10. Risks if treatment not administered: 11. What altemative(s) to medication has been considered or tried: 12. If no alternative(s) considered or tried, explain why: 13. If alternative(s) was rejected, explain why: 14. The possible risks, benefits, and side effects have been explained to the minor in age-appropriate language: Yes No 15. Minor If no, explain why not: IS IS NOT pregnant. 16. The risks of taking the medication while pregnant have been discussed with the minor: Yes No JV-SC7 In re: 05/15/00 Page 2 of 4 pages Case No. 2002 © American LegalNet, Inc. 17. The risks of combining the medication with drugs and alcohol have been discussed with the minor: Yes No 18. Minor is willing to take medication: Yes No 19. I obtained the minor's medical history from: 20. Other professionals currently involved in minor's care: Name and Profession Telephone Contacted Yes No Yes No Yes No 21. Additional Information: 22. The minor's current care provider has been advised of the information contained in this declaration, and has been informed that should any serious side effect occur I am to be called immediately and/or usual emergency measures No will be taken: Yes If no, explain why not: ,JV-SC7 In re: Case No. 05/15/00 Page 3 ot 4 pages 2002 © American LegalNet, Inc. 23. Physician's Specialization: Gen./Family Practice Child/Adoles. Psychiatry 24. I am am not Gen. Psychiatry Pediatrics Neurology Other: Board Certified or Board Eligible as a Child/Adolescent Psychiatrist. I hereby declare that the foregoing is true to the best of my knowledge. Dated: Physician's Signature Name: Address: Phone No:* Fax No: *Please list telephone number where physician can be reached personally and quickly, 24 hours a day. JV-SC7 05/15/00 In re: Case No. Page 4 of 4 pages 2002 © American LegalNet, Inc.