SUPERIOR COURT OF SACRAMENTO COUNTY OF SACRAMENTO SITTING AS THE JUVENILE COURT In the matter of Case No. ___________________ A minor Date of Birth: ____________________ REQUEST FOR COURT ORDER FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION (Welf. & Inst. Code § 300 Dependents) DEPT NO. __________ 1. Court action requested: ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. This Request supersedes a prior request for authorization: Yes No If yes, list the date of the prior Request: _______________________________________ 3. The parent/legal guardian (circle, as appropriate) was contacted and informed of the request to administer the proposed psychotropic medication: Yes No If yes, his or her response was as follows: _____________________________________ ________________________________________________________________________ ________________________________________________________________________ If no, explain why not: ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. I informed the parent/legal guardian that I intend to seek a court order without a hearing authorizing the administration of the psychotropic medication: Yes No If not, explain why not: ____________________________________________________________________________________________________________________________ JV-SC6 S:\MO\procedure\request.doc 05/15/00 Page 1 of 2 5. If unable to locate the parent/legal guardian, please detail the efforts made to locate and obtain his or her consent: __________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 6. For minors 12 years of age or older, is the minor willing to take the requested medication: Yes No If no, explain why not: _____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. Minor's current placement: _________________________________________________ ________________________________________________________________________ I have reviewed for completeness and legibility the documentation submitted by the minor's physician in support of this Request. The original and one copy of the submitted documents are attached. I declare the above to be true under penalty of perjury under the laws of the State of California. Executed on _______________ at ____________________, California. ____________________________________ Social Worker's Signature Name: _____________________________ (please print, stamp, or type) Phone No: __________________________ Dated: _____________________ Approved: __________________________ Name: _____________________________ (please print, stamp, or type) JV-SC6 S:\MO\procedure\request.doc 05/15/00 Page 2 of 2 In Re: ______________________ Case No. ____________________