ATTORNEY OR PARTY WITHOUT ATTORNEY(Name, state bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (Name): FAX NO.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO JUVENILE COURT 2851 MEADOW LARK DR., SAN DIEGO, CA 92123-2792 325 S. MELROSE DR., VISTA, CA 92081-6634 500 3RD AVE., CHULA VISTA, CA 91910-5649 250 E. MAIN ST., EL CAJON, CA 92020-3941 IN THE MATTER OF A MINOR ORDER DESIGNATING PERSON WHO MAY CONSENT TO PRESCRIBING CASE NUMBER: PSYCHOTROPIC MEDICATIONS/APPROVING A MEDICATION TREATMENT PLAN FOR A DEPENDENT OR WARD (Welfare & Institutions Code § 6552) 1. The Court has read and considered: a. b. c. d. The executed Request for Authorization for Medical, Surgical or Dental Treatment form. The Ex Parte Application. The written Medication Treatment Plan. The evidence presented. 2. The Court finds: a. All persons entitled to notice have received notice. b. Counsel of record have been served with the ex parte application. c. Reasonable efforts/due diligence has been undertaken to notify the: Mother Father Legal Guardian Other: d. No objection has been filed with the Court. e. An objection has been filed with the Court, and a hearing shall be set on at ____________o'clock, in Department __________ of the Juvenile Court. The Clerk of the Court is to notice all parties and counsel. 3. THE COURT ORDERS: a. Nothing in this Order is to be construed as interfering with or superseding a licensed physician's duty and judgment in an emergency situation. b. Nothing in this Order is to be construed as limiting or superseding an involuntarily hospitalized minor's refusal to take medications. c. The following person(s) SHALL NOT be authorized to consent on behalf of the minor: Mother: Father: Legal Guardian: Other: ORDER DESIGNATING PERSON WHO MAY CONSENT TO PRESCRIBING PSYCHOTROPIC MEDICATIONS/ APPROVING A MEDICATION TREATMENT PLAN FOR A DEPENDENT OR WARD Page one of two American LegalNet, Inc. www.FormsWorkflow.com SDSC JUV-58(Rev. 10-06) CASE NUMBER: d. The following person(s) SHALL be authorized to consent on behalf of the minor: . e. The minor shall be authorized to consent on his/her behalf: The minor has signed an application under Welfare and Institutions Code § 6552, which application has been approved by the Court; or The minor is at least 12 years of age and the Court has previously determined that parental consent is not required. f. The Medical Treatment Plan is APPROVED. g. Other: Date: Judicial Officer SDSC JUV-58(Rev. 10-06) ORDER DESIGNATING PERSON WHO MAY CONSENT TO PRESCRIBING PSYCHOTROPIC MEDICATIONS/ APPROVING A MEDICATION TREATMENT PLAN FOR A DEPENDENT OR WARD Page two of two