Fill and Sign the Form Jv 223 Order on Application for Psychotropic

JV-223, Page 1 of 2 Judicial Council of California, www.courts.ca.gov Revised January 1, 2018, Mandatory Form Welfare and Institutions Code, §§ 369.5, 739.5 California Rules of Court, rule 5.640 Order on Application for Psychotropic Medication The Court read and considered: The Court finds and orders: at (time): The matter is set for hearing on ( date): in (dept.): 1 2 a. b. 3 a. b. The application is (check one): Copies of pages 5 and 6 of form JV-220(A) or pages 3 and 4 of form JV-220(B) are attached to this order . h. Clerk stamps date here when form is filed. Fill in court name and street address: Superior Court of California, County of Court fills in case number when form is filed. Case Number: Fill in child's name and date of birth: Order on Application for Psychotropic Medication JV-223 Other (specify): Notice requirements were met. Notice requirements were not met. Proper notice was not given to: Application was made for authorization to begin or to continue giving the child the psychotropic medication listed in on page 5 of form JV-220(A) or on page 4 of form JV-220(B). 19 Granted as requested. Granted with the following modifications or conditions to the request as made in on page 5 of form JV-220(A) or on page 4 of form JV-220(B) (specify all modifications and conditions): b. Form JV-218 , Child’s Opinion About the Medicine, g. CASA report c. Form JV-219, Statement About Medicine Prescribed, filed on (date): filed on (date): c. If the application was for medication the child is currently taking, the social worker or probation officer must consult with the prescribing physician to determine whether the physician is ordering that the medication should be stopped immediately or gradually reduced over time. Child's Name: Date of Birth: d. Form JV-219, Statement About Medicine Prescribed, filed on (date): 16 16 19 f. filed on (date): Form JV-222, Input on Application for Psychotropic Medication, e. filed on (date): Form JV-222, Input on Application for Psychotropic Medication, a. Form JV-220, Application for Psychotropic Medication, and form JV-220 (A), Physician’s Statement—Attachment, or JV-220(B), Physician’s Request to Continue Medication—Attachment filed on (date): Denied (specify reason for denial): JV-223, Page 2 of 2 Rev. January 1, 2018 Date: This order is effective until terminated or modified by court order or until 180 days from the date of this order, whichever is earlier. If the prescribing physician is no longer treating the child, this order extends to subsequent treating physicians. A change in the child’s placement does not require a new order regarding psychotropic medication. Except in an emergency situation, a new application must be submitted and consent granted by the court before giving the child medication not authorized in this order or increasing medication dosage beyond the maximum daily dosage authorized in this order. Order on Application for Psychotropic Medication Signature of judge or judicial officer Other (specify): Child’s name: Case Number: 6 The social worker probation officer a. b. person who submitted application c. is ordered to give a copy of this order, including pages 5 and 6 of form JV-220(A) or pages 3 and 4 of form JV-220(B) and the medication monograph attached to the form JV-220(A) to the child’s caregiver either in person or by mail within two court days. 4 The applicant must resubmit the application no later than (date): 5 7 at (time): The matter is set for hearing on ( date): in (dept.): at (time): The order is set for a progress review on ( date): in (dept.): with the missing information, which is: Print this form Save this form Clear this form For your protection and privacy, please press the Clear This Form button after you have printed the form.