Free jv220 - California

JV-220
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): FOR COURT USE ONLY

TELEPHONE NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

CHILD'S NAME:

Attachments
CASE NUMBER:

APPLICATION FOR ORDER FOR PSYCHOTROPIC MEDICATION-JUVENILE

1. The child is a dependent ward of the court under Welfare and Institutions Code section 602, and was removed from the custody of his or her parent or guardian on (date): 2. Child's date of birth: 3. The child is currently placed in: relative's home foster home Child's weight: group home juvenile hall camp

300

601

other (specify): 4. Applicant is child's treating physician social worker on behalf of physician probation officer on behalf of physician Letter or Declaration by Physician included as Attachment 4.

a. Name of treating physician: b. Address and phone number of treating physician: c. Employer of physician: d. Medical specialty of physician: e. Board eligibility/certification: f. Date of evaluation of child: g. Location of evaluation:

5. Applicant requests the court to: authorize the administration to the child of the psychotropic medication(s) described in section 9 below; or a. authorize (name and address): b. legal guardian as established by the who is the child's mother statutorily presumed father Probate or Juvenile Court, to consent to the administration of the psychotropic medication(s) described in section 9 below. The child's parent or legal guardian poses no danger to the child and has the capacity to authorize the administration of the medication(s) (describe bases for this statement):

Continued on Attachment 5. 6. The child has been diagnosed as suffering from the following mental disorder(s) (state DSM-IV Diagnosis [Axes I to III]):

Continued on Attachment 6.
Page one of four Form Adopted for Mandatory Use Judicial Council of California JV-220 [New January 1, 2001]

APPLICATION FOR ORDER FOR PSYCHOTROPIC MEDICATION-JUVENILE

Welfare and Institutions Code, § 369.5

CHILD'S NAME:

CASE NUMBER:

7. The child's relevant psychiatric history is as follows (specify current behaviors likely to be helped by psychotropic medication):

Continued on Attachment 7. 8. Other treatment interventions in addition to the requested medication(s) are: Individual therapy Group therapy Family therapy Other (describe):

9. The following psychotropic medication is recommended: a. Name (trade and generic): b. Category: C. Anticipated range of dosage: d. Anticipated treatment duration: e. Alternative medications in same category (specify name of drug): Anticipated benefits to the child (specify): f. Medication is approved for pediatric use.

Continued on Attachment 9. 10. The relevant medical and medication history of the child is as follows (specify all medication the child is currently taking, including prescription and nonprescription medications): See Attachment 10. a. The possible interaction with the recommended medications is as follows (specify all possible effects of combining the medications): See Attachment 10 a. b. The administration of the requested psychotropic medications will require the following adjustments of the current regimen of medications (specify any discontinuations or changes in dosages): See Attachment 10 b. 11. Significant adverse reactions, warnings/contraindications, drug interactions, withdrawal symptoms, and anticipated time lag before full effect for each recommended medication are attached as narrative. attached as document prepared by manufacturer or health care provider. 12. The child has been informed of this request, the medications that are recommended, their anticipated benefits, and their possible adverse reactions. The child's response was (describe):

Continued on Attachment 12. (Child's own written statement may be included.)

JV-220 (New January 1, 2001

APPLICATION FOR ORDER FOR PSYCHOTROPIC MEDICATION-JUVENILE

Page two of four

CHILD'S NAME:

CASE NUMBER:

13. a. The child's mother statutorily presumed father legal guardian has been informed of this request, the medications that are recommended, their anticipated benefits, and possible adverse reactions. b. No parent or guardian has been informed because (state reasons):

C.

The response of the parent or guardian was as follows:

Continued on Attachment 13 c. d. A parent or legal guardian has not received notice because their whereabouts are unknown.

14. a. b.
C.

All attorneys of record have been informed of this request. The mother's attorney The father's attorney The child's attorney does not oppose does not oppose does not oppose opposes the application and requests a hearing. opposes the application and requests a hearing. opposes the application and requests a hearing.

15.

The child's present caregiver has been informed of this request, the medications that are recommended, their anticipated benefits, and possible adverse reactions. The response of the caregiver was as follows:

Continued on Attachment 15. 16. A psychiatrist has reviewed this application. The psychiatrist agrees. The psychiatrist does not agree.

(Signature of psychiatrist)

(Type or Print Name)

17.

Other professionals who were informed and consulted (state names and professional relationship to the case):

18. Other information or comments: Date:

Continued on Attachment 18.

(TYPE OR PRINT NAME)

(SIGNATURE OF APPLICANT)

JV-220 [New January 1, 2001]

APPLICATION FOR ORDER FOR PSYCHOTROPIC MEDICATION-JUVENILE

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CHILD'S NAME:

CASE NUMBER:

ORDER

The matter is set for hearing within 5 court days on (date) The clerk is to notice all parties and counsel. The application for authorization to administer psychotropic medications is: Granted as requested Denied Granted, with the following modifications or conditions:

at (time):

The court finds that the parent poses no danger to the child and has the capacity to authorize the administration of psychotropic medications, and the request for such authority is granted As requested With the following modifications or conditions:

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 physician named above is no longer treating the child, the authorization may extend to physicians who subsequently treat the child. If a new treating physician proposes an increase in the dosage or a change in or the addition of other medications, a new application must be submitted.

Date:

(TYPE OR PRINT NAME)

(JUVENILE COURT JUDICIAL OFFICER)

JV-220 [New January 1, 20011

APPLICATION FOR ORDER FOR PSYCHOTROPIC MEDICATION-JUVENILE

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