Free Psychotropic Medication Authorizing Form - California

« SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES »

Psychotropic Medication Authorization Form

LOG #

THIS FORM MUST BE FAXED TO THE PROPER LOCATION BELOW TO OBTAIN COURT AUTHORIZATION PRIOR TO THE ADMINISTRATION OF PSYCHOTROPIC MEDICATION, ABSENT AN EMERGENCY .
D EPENDENCY : FAX: (562) 941-7205 D ELINQUENCY : FAX: ( 323) 441-1110
OR

( 323) 441-1120 D.O.B.
Sex

A. IDENTIFYING INFORMATION
Child's Name (Last, First, MI)

Please include this form with discharge packet!
Ethnicity

To keep other people from seeing what you entered on your form, please press the Clear This Form button at the end of this form when finished.
Court Case No. Plcmt. Contact Person

For Court Use Only

Ct. Dept.

Child's Current Placement Name and Address

Phone Fax

Placement Type

Relative Foster Home Group Home

Facility:

B.J. Nidorf Juv. Hall Central Juv. Hall Los Padrinos Juv. Hall

Probation Camp Dorothy Kirby Center

State Hospital Developmental Center

County Jail Other

Acute Hospital Name: Address: CSW/DPO: Name:

Phone Fax Region/Office:

Hosp. Contact Person

Phone:

Name of Prescribing Physician (print) Specialty: Address: Office Phone:
SECTIONS B & C ON PAGES

License No.
Neuro. Child/Adolesc.Psychiatry Gen.Psych. Other:

Gen./Family Practice

Pediatrics

Emergency Phone: 1&2

Fax:

MUST BE PERSONALLY COMPLETED AND SIGNED BY THE PRESCRIBING PHYSICIAN.

B. CLINICAL INFORMATION
B1. Date child last seen by physician: B2. Information about child from: childcaregiverWho brought child/what is relationship? teacherrecordsother Present illness d uration:

B3. Diagnosis: (DSM IV Dx & Codes required)

B4. Current therapeutic services other than medication (specify type, frequency, location):

B5. Last Physical Exam (Minor must have had physical exam during the 12 months prior to starting psychotropic medication and then yearly.) Date of PE: Current Height: Location of PE records: Weight: Date Measured: No No Yes Yes

Significant Medical Problems or Lab Test, BP or Pulse Abnormalities: Non-psychotropic prescribed medications taken regularly:

}

If Yes, describe below or attach information.

B6. Indicate relevant laboratory tests performed or ordered. CBC UA Liver Function Thyroid Function

No lab work done/ordered Kidney Function Other: Glucose Lipid Panel Electrolytes EKG

Medication Blood Level (specify):

B7. Current Psychotropic medication request is: Continuation of Rx Only Non-emergency Emergency Nature and circumstances of emergency must be specified here to allow for temporary administration pending judicial order:
(Administration of Continued medication or Emergency medication may proceed immediately upon submission of form.)

Psychotropic Medication Authorization Form (PMAF) 10-24-05

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Child's Name (Last, First, MI)

LOG #

C. MEDICATIONS (List all psychotropic medications now being taken or to be taken when authorized or being discontinued.)
Mark them N ew-C ontinued-D iscontinued (with respect to the child not the prescribing physician) (Use additional sheet if needed.) Indicate if cross titrating medications. C1. NAME OF MEDICATION (S)
AND

If use of a medication is to be short-term (less than 6 months), specify time frame.

N
or

ADMINISTRATION SCHEDULE · · · · Indicate Initial and Target Schedules for New Rx Indicate Current Schedule for Continued Rx Indicate mg/dose and # of doses/day If PRN, specify conditions & parameters of use
M AXIMUM TOTAL DOSE/DAY

C
or

TARGET SYMPTOMS FOR EACH
Med: Targets:

D

Med: Targets:

Med: Targets:

Med: Targets:

Med: Targets:

Med: Targets:

C2. Indicate response to ongoing Rx treatment and reasons for any Rx changes (with respect to target symptoms &/or adverse effects):

C3. Prior medications: C4. a. b. C5.
(Completion of C4 a. or b. is required.) (Complete C5 and/or C6 if they are applicable.)

Child has been informed of the proposed medication treatment, anticipated benefits and potential adverse effects. Child is agreeable to opposed to the proposed treatment. (Child's own written statement may be attached.)

Child has not been informed because the child is too young and/or lacks the capacity to understand the treatment or provide a response. Child's current Foster Parent or Relative Care taker has been informed of the proposed medication treatment, anticipated benefits and potential adverse effects. Foster parent or Relative Caretaker is agreeable to opposed to the proposed treatment (Use additional sheet if needed.) Child's Parent or Legal Guardian (circle one) will not or cannot consent to the proposed treatment. Additional explanation (Use additional sheet if needed.):

C6.

I hereby declare that all the foregoing is true to the best of my knowledge.

Prescribing Physician's Signature

Date

Psychotropic Medication Authorization Form (PMAF) 10-24-05

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Child's Name (Last, First, MI)

LOG #

D. NOTICE
· Parent/Guardian Notice sent on:
Date

Notifying Agency:

Probation

DCFS

By:
Print Name Sign

If not sent, reason: · Child's Attorney Notice sent by Court on:
Date

By:
Print Name Sign

If not sent, reason:

E. JCMHS REVIEW
This form has been reviewed by staff of Juvenile Court Mental Health Services. This review is intended to give the court general information regarding the appropriateness of the psychotropic medication treatment for which authorization is requested given the clinical information indicated on the form (age, diagnosis, symptoms, etc.). See attached JCMHS review page for further information.

F. COURT ORDER

(to be completed by the court)

Court having read and considered the above request:
· · The matter is set for a hearing within five court days on (date): The application for authorization to administer psychotropic medication is a) b) Granted as requested Denied (specify reason for denial): at (time): in department:

c)

Granted with the following modifications or conditions (specify):

·

This order for authorization is effective until terminated or modified by court order or until 180 days from this order, whichever is earlier. If the prescribing physician named above is no longer treating the child, the authorization may extend to physicians who subsequently treat the child. Except in an emergency situation, an increase in the dosage beyond the approved maximum daily dosage or a change in or the addition of other medications requires the treating physician to submit a new application. A change in the child's placement does not require a new order for psychotropic medication, and this authorization, if it is still in effect, must accompany the child if placement is changed. Notice Requirements a) b) The notice requirements have been met. The notice requirements have NOT been met. Proper notice was not given to:

·

Date:
Print Name Sign

Judicial Officer of the Juvenile Court

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