Cfs 431 A Form PDF Details

Ensuring the wellbeing and proper medical care for children under its guardianship is a critical responsibility of the Illinois Department of Children & Family Services (DCFS). Within this context, the CFS 431-A form plays a pivotal role, acting as a structured channel for requests related to psychotropic medication for children in the care of DCFS. Revised in August 2006, this form requires comprehensive information, including the child's identification details, current placement (ranging from foster care to hospitals), and the prescribing physician's particulars. It stipulates the necessity to list current psychotropic medications, noting dosage and frequency, and outlines the procedure to request new medications, increases, renewals, or single-time orders. Emphasizing clinical responsibility, the form mandates the listing of concurrent medical and psychiatric diagnoses, along with any previously discontinued psychotropic medication. Importantly, it also recognizes the need for informed consent and consideration of the child's voice, mandating confirmation whether potential side effects have been discussed with the child and if the child, provided they are 12 or older, objects to the medication. The inclusion of alternative treatments and reasons for their failure or rejection underscores a preference for a comprehensive approach to the child's healthcare, ensuring medication is used judiciously and as part of a broader treatment strategy.

QuestionAnswer
Form NameCfs 431 A Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesIllinois, DCFS, dcfs psychotropic medication request form, PSYCHOTROPIC

Form Preview Example

CFS 431-A

Rev. 8/2006

Illinois Department of Children & Family Services

PSYCHOTROPIC MEDICATION REQUEST FORM

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CFS ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8digits)

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

Ethnicity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Height

 

 

Weight

 

 

 

Placement:

 

 

 

 

 

Foster Care

 

 

 

 

 

 

Residential

 

 

 

DOC

 

Hospital

 

 

 

Family of Origin

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_ Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescribing Physician

 

 

 

 

 

 

 

 

 

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

Check DCFS/POS Region

 

 

 

 

 

 

Cook County

 

 

Northern

 

 

 

Central

 

 

Southern

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concurrent Medical Diagnoses:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All Psychiatric Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Psychotropic Medications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

 

 

 

 

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

 

 

 

 

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

 

 

 

 

Discontinued Psychotropic Medications:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication/Dosage/Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Info/Other Medications:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Request

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

 

 

 

New

Increase*

 

180 Day Renewal*

 

 

Resume

One Time Order

 

 

 

New Ward, Current Medication

 

 

 

 

 

 

 

 

 

 

 

*If medication request is for an Increase or Renewal include the current dosage in the Clinical Information section.

 

 

 

 

 

 

 

 

Brand Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chemical Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

 

 

Dosage

 

 

 

 

Frequency

 

 

 

 

 

 

 

 

 

 

Range

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duration (not to exceed 180 days)

 

 

 

 

Symptoms for Medication Requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tests/Procedures prior to and to monitor medication requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternative Treatment/Medications*:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*List alternative treatment methods and medications considered/attempted and the reasons they failed or were rejected.

 

 

 

 

 

 

 

 

Potential side effects reviewed with child?

 

Yes

No If the child is 12 years of age or older, does he/she object to medication?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

 

 

 

New

 

Increase*

 

 

180 Day Renewal*

 

 

 

Resume

 

 

One Time Order

 

 

 

New Ward, Current Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If medication request is for an Increase or Renewal include the current dosage in the Clinical Information section.

 

 

 

 

 

 

 

 

Brand Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chemical Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

 

 

Dosage

 

 

 

 

Frequency

 

 

 

 

 

 

 

 

 

 

Range

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duration (not to exceed 180 days)

 

 

 

 

Symptoms for Medication Requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tests/Procedures prior to and to monitor medication requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternative Treatment/Medications*:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*List alternative treatment methods and medications considered/attempted and the reasons they failed or were rejected.

 

 

 

 

 

 

 

 

Potential side effects reviewed with child?

 

Yes

No

If the child is 12 years of age or older, does he/she object to medication?

 

 

Yes

No

Check One: New

Increase*

180 Day Renewal*

Resume

One Time Order

New Ward, Current Medication

*If medication request is for an Increase or Renewal include the current dosage in the Clinical Information section.

Brand Name

 

 

 

 

Chemical Name

 

 

 

 

Form

 

 

Dosage

 

Frequency

 

 

Range

 

 

Duration (not to exceed 180 days)

 

 

Symptoms for Medication Requested:

Tests/Procedures prior to and to monitor medication requested:

Alternative Treatment/Medications*:

*List alternative treatment methods and medications considered/attempted and the reasons they failed or were rejected.

Potential side effects reviewed with child?

Yes No If the child is 12 years of age or older, does he/she object to medication?

Yes

No

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431-A writing process shown (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Brand Name, Chemical Name, Form Dosage, Frequency, Range, Duration not to exceed days, Symptoms for Medication Requested, TestsProcedures prior to and to, Alternative TreatmentMedications, Potential side effects reviewed, Yes, No If the child is years of age, Yes, List alternative treatment methods, and Check One with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Tips to fill in 431-A portion 2

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