Free JV-220 v9 101007 mc.ofm - California

JV-220

Application Regarding Psychotropic Medication

Clerk stamps date here when form is filed.

Attach a completed and signed JV-220(A), Prescribing Physician's Statement--Attachment, with all its attachments, must be attached to this form before it is filed with the court. Read JV-219-INFO, Information About Psychotropic Medication Forms, for more information about the required forms and the application process. 1 Information about where the child lives: a. The child lives in a foster home with a relative with a nonrelative extended family member in a regular group home in a level 12­14 group home at a juvenile ranch at a juvenile camp other (specify): b. If applicable, name of facility where child lives: c. Contact information for responsible adult where child lives: (1) Name: (2) Phone: 2 Information about the child's current location: a. The child remains at the location identified in 1 . b. The child is currently staying in: (1) (2) (3) 1 3 Child's a. Name: b. Address: c. Phone: a psychiatric hospital (name): a juvenile hall (name): other (specify): social worker probation officer

Fill in court name and street address:

Superior Court of California, County of

Fill in child's name and date of birth:

Child's Name: Date of Birth:
Clerk fills in case number when form is filed.

Case Number:

Fax:

4

Number of pages attached: Date:

Type or print name of person completing this form

Signature Child welfare services staff (sign above) Probation department staff (sign above) Medical office staff (sign above) Caregiver (sign above) Prescribing physician (sign on page 3 of JV-220(A))

Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2008, Mandatory Form Welfare and Institution Code, § 369.5 California Rules of Court, rule 5.640

Application Regarding Psychotropic Medication

JV-220, Page 1 of 1

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