Cfs 431 A Form PDF Details

Cfs 431 A form is a important document for any small business. This form is used to calculate the amount of money that a company owes to its employees. Understanding this form and how to complete it correctly is critical for ensuring that your small business operates smoothly and under compliance with labor laws. In this blog post, we will walk you through the basics of Cfs 431 A form so that you can understand how it works and use it correctly in your own business. Thank you for reading!

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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As a way to finalize this PDF form, ensure you type in the necessary information in every blank field:

1. The dcfs psychotropic medication request form involves particular details to be inserted. Ensure that the subsequent blank fields are filled out:

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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