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JV-220(A) | Unnamed: 1 | Prescribing Physician's Statement - Attachment | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Case Number: | Unnamed: 8 | Unnamed: 9
This form must be completed and signed by the prescribing physician.  Read JV-219-INFO, Information About
Psychotropic Medication Forms, for more information about the required forms and the application process.
1.   Information  about  the  child  (name):
Date of birth: |  |  | Current height: |  |  | Current weight:
Gender: |  |  | Ethnicity:
2   Type of request:
a. | An initial request to administer psychotropic medication to this child
b. | A request to continue psychotropic medication the child is currently taking.
3           This application is made during an emergency situation.  The emergency circumstances requiring the
temporary administration of psychotropic medication pending the court's decision on this application are:
4  Prescribing physician:
a.  Name: |  |  |  |  |  | License number:
b.  Address:
c. Phone Number:
d.  Medical specialty of prescribing physician:
Child/adolscent psychiatry |  |  | General psychiatry |  | Family practice/GP |  |  | Pediatrics
Other (specify)
5  This request is based on a face-to face clinical evaluation of the child by:
a.        the prescribing physician on (date):
b. | other (provide name, professional status, and date of evaluation):
6  Information about child provided to the prescribing physician by (check all that apply):
child | caregiver |  | teacher | social worker |  | probation officer |  | parent
records (specify)
Other (specify)
7  Describe the child's symptoms, including duration as well as the child's response to any current psychotropic
medication.  If the child is not currently taking psychotropic medication, describe treatment alternatives to the
proposed adminstration of psychotropic medication that have been tried with the child in the last six months.
If no alternatives have been tried, explain the reason for not doing so.
 |  | Prescribing Physician's Statement - Attachment |  |  |  |  |  | JV-220(A), Page 1 of 3
Judicial Council of California, www.courtinfo.ca.gov |  |  |  |  |  |  |  |  | →
New January 1, 2008, Mandatory Form |  |  |  |  |  |  |  | American LegalNet, Inc.
Welfare and Institutions Code, § 369.5 |  |  |  |  |  |  |  | www.FormsWorkflow.com
California Rules of Court, rule 5.640
 |  |  |  |  |  |  | Case Number:
Child's Name: |  | 0 |  |  |  |  | 0
8    Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
(provide full Axis I and Axis II diagnoses; inclusion of numeric codes is optional):
9   Therapeutic services, other than medication, in which the child will participate during the next six months
(check all that apply; include frequency for group therapy and individual therapy):
a.             Group therapy: |  |  |  |  | b.            Individual therapy:
c.             Milieu therapy (explain):
d.             Other modality (explain):
10  a.  Relevant medical history (describe, specifying significant medical conditions, all current non-
psychotropic medications, date of last physical examination and any recent abnormal lab results):
b.  Relevant laboratory tests performed or ordered (optional information;provide if required by local court rule):
kidney function |  | liver function |  | thyroid function |  | UA | glucose |  | lipid panel
CBC |  | EKG | pregnancy |  | medication blood levels (specify):
other (specify):
11  Mandatory Information Attached:  Significant side effects, warning/contraindications, drug interactions
(including those with continuing psychotropic medication and all nonpsychotropic medication currently taken by
the child), and withdrawal symptoms for each recommended medication are included in the attached material.
12  a.        The child was told in an age-appropriate manner about the recommended medications, the anticipated
benefits, the possible side effects and that a request to the court for permission to begin and/or continue
the medication will be made and that he or she may oppose the request.  The child's response was
 | agreeable |  | other (explain):
b.        The child has not been informed of this request, the recommended medications and their anticipated
 | benefits, and their possible adverse reactions because:
 | (1)         the child is too young
 | (2)         the child lacks the capacity to provide a response (explain):
 | (3)         other (explain):
13  The child's present caregiver was informed of this request, the recommended medications, the anticipated
benefits, and the possible adverse reactions.  The caregiver's response was
14  Additional information regarding medication treatment plan:
New January 1, 2008 |  | Prescribing Physician's Statement - Attachment |  |  |  |  |  | JV-220(A), Page 2 of 3
 |  |  |  |  |  |  | Case Number:
Child's Name: |  | 0 |  |  |  |  | 0
15  List all psychotropic medications currently administered that you propose to continue and all psychotropic
medications you propose to begin administering.  [NAME] each psychotropic medication as New (N) or
Continuing (C).  Administration schedule is optional information; provide if required by local court rule.
Medication name (generic or brand) and symptoms targeted by each medication's anticipated benefit to child |  |  | "C"             or             "N" | Maximum total    mg/day | Treatment duration* | Adminstration schedule (optional)                                                                    • Initial and target schedule for new medication                                        • Current schedule for continuing medication                                               • Provide mg/dose and # of dose/day                                                                                                        • If PRN, provide conditions and parameters for use
Med:
Targets:
Med:
Targets:
Med:
Targets:
Med:
Targets:
*Authorization to administer the medication is limited to this time frame or six months from the date the order is issued, whichever occurs first.
16  List all psychotropic medications currently administered that will be stopped if this application is granted.
Medication name (generic or brand) |  |  | Reason for stopping
17  List the psychotropic medication that you know were taken by the child in the past and the reason or reasons
these were stopped if the reasons are known to you.
Medication name (generic or brand) |  |  | Reason for stopping
Date:
Type or print name of prescribing physician |  |  |  |  | Signature of prescribing physician
New January 1, 2008 |  | Prescribing Physician's Statement - Attachment |  |  |  |  |  | JV-220(A), Page 3 of 3