Jv 220 A Form PDF Details

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QuestionAnswer
Form NameJv 220 A Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesjv220a Prescribing Physician's

Form Preview Example

JV-220(A)

Physician’s Statement—

 

Attachment

 

Case Number:

This form must be completed and signed by the prescribing physician. Read form JV-217-INFO, Guide to Psychotropic Medication Forms, for more information about the required forms and the application process.

1Information about the child (name):

Date of birth:

 

 

Current height:

 

 

Current weight:

Gender:

 

Ethnicity:

 

 

 

 

2Type of request:

a. An initial request to administer psychotropic medication to this child

b. A request to start a new medication or to increase the maximum dose of a previously approved medication

c. A request to continue psychotropic medication the child is currently taking

3

4

This application is made during an emergency situation as defined in California Rules of Court, rule 5.640(i). The emergency circumstances requiring the temporary administration of psychotropic medication pending the court’s decision on this application are:

Prescribing physician:

 

a. Name:

License number:

b.Address:

c.Phone numbers:

d.Medical specialty of prescribing physician:

Child/adolescent psychiatry

General psychiatry

Family practice/GP

Pediatrics

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. How long have you been treating the child?

 

years

months

days

 

 

 

 

 

 

 

 

 

f. In what capacity have you been treating the child (e.g., treating psychiatrist, treating pediatrician)?

5This 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):

6Information about the child was provided to the prescribing physician by (check all that apply):

Child

Caregiver

Teacher

Social worker

Probation officer

Parent

Public health nurse

Tribe

 

 

 

 

Records (specify):

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Judicial Council of California, www.courts.ca.gov

Physician’s Statement—Attachment

JV-220(A), Page 1 of 6

Revised January 1, 2018, Mandatory Form

 

 

Welfare and Institutions Code, §§ 369.5; 739.5

California Rules of Court, rule 5.640

Child’s name:

Case Number:

7 Provide to the court your assessment of the child’s overall mental health.

I don’t know.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8 Describe the child’s symptoms, including duration, and the child’s treatment plan.

I don’t know.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9 a. Describe the child’s response to any current psychotropic medication.

I don’t know.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Describe the symptoms not alleviated or ameliorated by other current or past treatment efforts.

I don’t know.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 2 of 6

 

 

Child’s name:

Case Number:

10a. Have nonpharmacological treatment alternatives to the proposed medications been tried in the last six months?

Yes

No

I don’t know.

b. If yes, describe the treatment and the child’s response. If no, explain why not.

11a. Have other pharmacological treatment alternatives to the proposed medications been tried in the last six months?

Yes

No

I don’t know.

b. If yes, describe the treatment and the child’s response. If no, explain why not.

c.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.

Medication name (generic or brand) Reason for stopping

12Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 3 of 6

 

 

Child’s name:

Case Number:

13

14

15

Relevant medical history (describe, specifying significant medical conditions, all current nonpsychotropic

medications, date of last physical examination, and any recent abnormal laboratory results):

I don’t know.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. All essential laboratory tests were performed.

b. All essential laboratory tests were not performed (explain what laboratory tests were not done and why).

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

not agreeable

Briefly describe child’s response:

b. The child has not been informed of this request, the recommended medications, their anticipated benefits, and their possible adverse reactions because:

(1) The child lacks the capacity to provide a response (explain):

(2) other (explain):

16Therapeutic services, other than medication, in which the child is enrolled in or is recommended to participate during the next six months (check all that apply; include frequency for therapy on blank line):

a.

Group therapy:

 

b.

Individual therapy:

c. 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):

l. Other modality (explain):

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 4 of 6

 

 

 

Child’s name:

Case Number:

17a. Mandatory Information Attached: Significant side effects, warnings/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.

b.

c.

The caregiver was informed of the mandatory information, which is attached.

The caregiver’s response was

agreeable

other (explain):

18Additional information regarding medication treatment plan and follow-up:

19List all psychotropic medications currently administered that you propose to continue and all psychotropic medications you propose to begin administering. Mark each psychotropic medication as New (N) or Continuing (C).

 

Medication name (generic/brand) and

 

C

 

Maximum

 

Treatment

 

Administration schedule

 

 

 

 

 

 

 

 

 

 

 

 

• Initial and target schedule for new medication

 

 

 

or

 

total

 

duration*

 

 

 

class, and symptoms targeted by each

 

 

 

 

 

 

 

 

 

 

• Current schedule for continuing medication

 

 

 

N

 

mg/day

 

6-month

 

 

 

medication’s anticipated benefit to child

 

 

 

 

• Provide mg/dose and # of doses/day

 

 

 

 

 

 

 

maximum

 

 

 

 

 

 

 

 

 

 

 

• If PRN, provide conditions and parameters for use

 

 

 

 

 

 

 

 

 

 

 

 

 

Med:

 

 

 

 

 

 

 

 

 

 

Class:

 

 

 

 

 

 

 

 

 

 

Targets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Med:

 

 

 

 

 

 

 

 

 

 

Class:

 

 

 

 

 

 

 

 

 

 

Targets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Med:

 

 

 

 

 

 

 

 

 

 

Class:

 

 

 

 

 

 

 

 

 

 

Targets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Med:

 

 

 

 

 

 

 

 

 

 

Class:

 

 

 

 

 

 

 

 

 

 

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.

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 5 of 6

 

 

Child’s name:

Case Number:

20Other information about the prescribed medication that you want the court to know (e.g., reasons for prescribing more than one medication in a class, prescribing outside the approved range, or prescribing medication not approved for a child of this age):

21List all psychotropic medications currently administered that will be stopped if this application is granted.

Medication name (generic or brand) Reason for stopping

Stop immediately or over period of time? (specify, including time)

Date:

Type or print name of prescribing physician

Signature of prescribing physician

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 6 of 6

 

 

 

 

 

 

 

 

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Completing this document calls for thoroughness. Ensure that all required blank fields are done accurately.

1. Begin filling out your Jv 220 A Form with a group of major blank fields. Gather all the important information and make certain nothing is left out!

Part number 1 of completing Jv 220 A Form

2. Soon after filling out the last part, go on to the subsequent stage and fill in the necessary particulars in these fields - Prescribing physician, a b, Name, Address, Phone numbers, License number, Medical specialty of prescribing, Childadolescent psychiatry Other, General psychiatry, Family practiceGP, Pediatrics, How long have you been treating, years, months, and days.

Jv 220 A Form writing process clarified (part 2)

3. This next segment should be pretty uncomplicated, Caregiver, Child Public health nurse Records, Tribe, Teacher, Social worker, Probation officer, Parent, Judicial Council of California, Physicians StatementAttachment, and JVA Page of - all of these empty fields must be filled in here.

Find out how to fill out Jv 220 A Form step 3

4. To move ahead, your next part will require completing a handful of empty form fields. Examples of these are Provide to the court your, I dont know, Describe the childs symptoms, and I dont know, which are integral to continuing with this form.

I dont know, Provide to the court your, and I dont know of Jv 220 A Form

5. The form has to be finalized by filling out this segment. Further one can find a comprehensive list of blank fields that have to be filled in with correct information for your form submission to be complete: Describe the childs response to, I dont know, Describe the symptoms not, and I dont know.

Stage # 5 in filling in Jv 220 A Form

People generally make some mistakes when filling out I dont know in this area. Ensure that you review everything you type in right here.

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