COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. IDAHO CRIME VICTIMS COMPENSATION PROGRAM : Initial Treatment Plan Calendar No. Medication Management : JUDICIAL SUBPOENA Plaintiff(s) CV#: -againstParent/Guardian: Physician’s Name: Name of coordinating Therapist: Patient’s Name: : Tax I.D. #: : : Are you a provider under the following programs? Defendant(s) ! Medicaid . . . . . . . . . . . . . Medicare. . . . . . . . . . . . . . . . . . . TriCare . ! ........ ! .......: ...... ! Blue Cross ! Indian Health Services ! Blue Shield Other Indicate what sources of payment are available to the patient: THE PEOPLE OF Date treatment began: THE STATE OF NEW YORK Number of sessions to date: Are you providing individual psychotherapy to this patient? ! Yes ! No TO 1. Please describe the presenting symptoms or conditions for which the patient is seeking treatment. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable have a history of previous health conditions that have required medication? at the Court 2. Does the patient located at County of ! Yes ! No If so, indicate approximate dates of treatment, reasons for the medication, and results in room , on the day of , 20 , at o'clock in the noon, and at any recessed of the treatment. or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 3. Please provide a brief description of the crime as related to you, including the source of the Witness, Honorable , one of the Justices of the information (i.e. patient, parent or other). Court in County, day of , 20 (Attorney require medication to manage and 4. Please describe any pre-existing conditions that are present that must sign above and type name below) to what extent these conditions were exacerbated by the crime. Attorney(s) for 5. Please list any medications that the patient was taking prior to your assessment. Office and P.O. Address Medication Reason for Medication C:\formdocuments\Initial Treatment Plan – Med Mgmt (8/01) Dosage Duration Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 6. Indicate percentage of medication management you are providing for any pre-existing conditions. : % Calendar No. 7. Describe the symptoms/conditions you are treating that are:a direct result of the crime. JUDICIAL SUBPOENA Plaintiff(s) -against- : : 8. Indicate percentage of medication management you are providing for any conditions that are a direct result of the crime. : % (Percentages from #6 and #8 should equal 100%) Defendant(s) : .... ...... .... .... ... ... .. ... ....... 9. Please .indicate. how .often. you.will .see. this. patient. . . . . . . . . . . per 10. List below the medications you are prescribing and what symptoms/conditions they are treating, and whether that prescription is for conditions that are a direct result of the crime. THE PEOPLE OF THE STATE OF NEW YORK Medication TO Symptoms/Conditions being treated Crime Related? ! Yes ! Yes GREETINGS: ! No ! No WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ! Yes ! No , the Honorable at the Court located at County of ! Yes ! No in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the ! Yes ! No 11. I certify that the information provided in this treatment plan is true and accurate. I acknowledge Your failure to comply with this subpoena is will request the criminal court to order the alleged that if the alleged offender is convicted, the Program punishable as a contempt of court and will make you liable to the party onrestitution to this subpoena was issued for a maximum penalty ofbehalf ofall damages sustained as a offender to pay whose behalf reimburse the Program for expenses paid on $50 and the patient. I further result of that this document acknowledge your failure to comply.may be submitted as evidence and that I may be called to testify regarding the treatment outlined in this plan. Witness, Honorable Court in County, Signature of Physician , one of the Justices of the day of , 20 Date (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address C:\formdocuments\Initial Treatment Plan – Med Mgmt (8/01) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com