Fill and Sign the Jv 220 Application for Psychotropic Medication California Form

JV-220, Page 1 of 4 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 Number of pages attached: 4 Date: Signature Application for Psychotropic Medication (1) (2) 1 Information about where the child lives: a. The child lives c. Contact information for a responsible adult where the child lives: b. If applicable, the name of the facility where the child lives: 2 Information about the child’s current location: 1 a psychiatric hospital (name): a juvenile hall (name): other (specify): (1) (2) (3) a. b. Child’s 3 a. Name: Address: Phone: b. c. E-mail: A completed and signed Physician’s Statement—Attachment (form JV-220(A)), or Physician’s Request to Continue Medication— Attachment (form JV-220(B)) with all its attachments must be attached to this form before it is filed with the court. Read form JV-217-INFO, Guide to Psychotropic Medication Forms, for more information about the required forms and the application process. Type or print name of person completing this form 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: Application for Psychotropic Medication JV-220 with a relative in a foster home with a nonrelative extended family member in a group home, level at a juvenile custodial facility in a short-term residential therapeutic program other (specify): Name: Phone: d. The child has lived at the placement in (a) since (insert date): The child remains at the location identified in . The child is currently staying in: social worker probation officer Medical office staff (sign above) Caregiver (sign above) Prescribing physician (sign on page 6 of JV-220(A) or page 4 of JV-220(B)) Child welfare services staff (sign above, complete items – , and sign on page 4) Probation department staff (sign above, complete items – , and sign on page 4) 1 13 1 13 Child's Name: Date of Birth: Fax: JV-220, Page 2 of 4 Application for Psychotropic Medication Rev. January 1, 2018 Child ’s name: Case Number: If you are the child's social worker or probation officer, you must fill out items 5–13 of this form. If you do not know the answer to a question, write “I do not know.” If you are not the child’s social worker or probation officer, you do not need to fill out items 5–13 of this form. Describe if the child has shared feelings about starting to take medication. If this is a request to renew or modify medication, include what the child reports regarding the benefits and side effects of having taken the medication. The child will provide input on the medication being prescribed ( check all that apply): The caregiver will provide input on the medication being prescribed ( check all that apply): e. a. f. d. Through the social worker/probation officer. Through his or her attorney. Through his or her CASA. By filling out form JV-218. By writing a letter to the judge. By talking to the judge at a hearing. Other (specify): c. a. d. b. Through the social worker/probation officer. By filling out form JV-219. By writing a letter to the judge. By talking to the judge at a hearing. Other (specify): g. e. b. c. a. b. Is the information provided by the physician on form JV-220(A) at questions 10 and 11 or on form JV-220(B) at question 8 accurate, to the best of your knowledge? Do you have additional information about mental health treatment alternatives to the proposed medications that have been used in the last six months? If yes, explain: No I do not know 5 6 7 8 9 No Describe what the caregiver reports regarding the child being placed on the medication. If this is a request to renew or modify medication, include what the caregiver reports regarding the benefits and side effects of having the child take medication. Yes Yes JV-220, Page 3 of 4 Rev. January 1, 2018 Child ’s name: Case Number: d. List the psychotropic medications 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. 9 Therapeutic services, other than medication, which the child is enrolled in or is recommended to participate in during the next six months (check all that apply; include frequency for therapy on blank line): What other services could benefit or enhance the child’s well-being (for example, sports, art, extracurricular activities)? a. c. b. Group therapy: Individual therapy: Milieu therapy (explain): d. Therapeutic Behavioral Services (TBS): e. Therapy for children on the autism spectrum: f. Art therapy: g. Cognitive behavioral therapy (CBT): h. Wraparound services: i. American Indian/Alaska Native healing and cultural traditions: j. Speech therapy: k. In Home Behavioral Services (IHBS): Other modality (explain): 10 11c. Do you have additional information to add about other psychotropic medications that have been tried in the last six months? If yes, explain: No l. Application for Psychotropic Medication Medication name (generic or brand) Reason for stopping Yes JV-220, Page 4 of 4 Rev. January 1, 2018 Child ’s name: Case Number: What comments, if any, do you have regarding the application? What else do you want the judge to know? 12 Signature Date: Type or print name of person completing this form } Child welfare services staff (sign above) Probation department staff (sign above) Check here if you need more space for any of the items. Write the item number and additional information here. If you need more space, attach a sheet or sheets of paper. 13 Application for Psychotropic Medication 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.