DJJ Form HS001 "Acknowledgment of Receipt of Clinical Psychotropic Progress Note or Practitioner Form (Parental Consent for Psychotropic Medication)" - Florida

What Is DJJ Form HS001?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2007;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DJJ Form HS001 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS001 "Acknowledgment of Receipt of Clinical Psychotropic Progress Note or Practitioner Form (Parental Consent for Psychotropic Medication)" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
ACKNOWLEDGMENT OF RECEIPT OF
CLINICAL PSYCHOTROPIC PROGRESS NOTE OR PRACTITIONER FORM
(PARENTAL CONSENT FOR PSYCHOTROPIC MEDICATION)
N
Y
:
DOB:
DJJID#:
AME OF
OUTH
Date Mailed to Parent_______________ Facility Name: __________________________________________
Parent or Guardian Name
Mailing Address
City, State, Zip Code
Dear Mr./Mrs. _________________________________:
Your child saw the practitioner__________________________________ on ___________________________.
As part of your child’s treatment, the practitioner has recommended that your child be prescribed the
medication(s) listed on the attached form entitled Clinical Psychotropic Progress Note (CPPN) or the attached
practitioner form that was completed on the day your child was seen.
This letter has been sent to you to:
 Confirm your oral consent to initiate this treatment, which you gave on __________________________.
 Obtain your written consent to begin this treatment, as we were unable to contact you by other means. It
is important for you to contact us and return this form as soon as possible for treatment to begin.
We cannot begin the recommended treatment without your consent.
If you have questions or wish to speak to staff about these medications, please call the following number and
ask to speak to the contact person listed below:
Phone Number (
) __________________ Contact Person_______________________________________
PLEASE SIGN YOUR NAME AND DATE THE SIGNATURE ON THE LINES AT THE END OF THIS
FORM TO ACKNOWLEDGE YOUR RECEIPT OF THE ATTACHED INFORMATION AND TO
PROVIDE US WITH YOUR CONSENTFOR THE PSYCHOTROPIC MEDICATION LISTED ON THE
ATTACHED CPPN OR PRACTITIONER FORM. AFTER SIGNING, PLEASE MAIL THIS LETTER
BACK TO US AT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________
____________________________________
Parent/Guardian Signature
Date Signed
(The attached Clinical Psychotropic Progress Note (CPPN) form or practitioner form
that explains the medication is for you to keep. You do not need to send it back to us.)
Rule 63N-1
HS 001
Revised August 2007
Page 1 of 1
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
ACKNOWLEDGMENT OF RECEIPT OF
CLINICAL PSYCHOTROPIC PROGRESS NOTE OR PRACTITIONER FORM
(PARENTAL CONSENT FOR PSYCHOTROPIC MEDICATION)
N
Y
:
DOB:
DJJID#:
AME OF
OUTH
Date Mailed to Parent_______________ Facility Name: __________________________________________
Parent or Guardian Name
Mailing Address
City, State, Zip Code
Dear Mr./Mrs. _________________________________:
Your child saw the practitioner__________________________________ on ___________________________.
As part of your child’s treatment, the practitioner has recommended that your child be prescribed the
medication(s) listed on the attached form entitled Clinical Psychotropic Progress Note (CPPN) or the attached
practitioner form that was completed on the day your child was seen.
This letter has been sent to you to:
 Confirm your oral consent to initiate this treatment, which you gave on __________________________.
 Obtain your written consent to begin this treatment, as we were unable to contact you by other means. It
is important for you to contact us and return this form as soon as possible for treatment to begin.
We cannot begin the recommended treatment without your consent.
If you have questions or wish to speak to staff about these medications, please call the following number and
ask to speak to the contact person listed below:
Phone Number (
) __________________ Contact Person_______________________________________
PLEASE SIGN YOUR NAME AND DATE THE SIGNATURE ON THE LINES AT THE END OF THIS
FORM TO ACKNOWLEDGE YOUR RECEIPT OF THE ATTACHED INFORMATION AND TO
PROVIDE US WITH YOUR CONSENTFOR THE PSYCHOTROPIC MEDICATION LISTED ON THE
ATTACHED CPPN OR PRACTITIONER FORM. AFTER SIGNING, PLEASE MAIL THIS LETTER
BACK TO US AT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________
____________________________________
Parent/Guardian Signature
Date Signed
(The attached Clinical Psychotropic Progress Note (CPPN) form or practitioner form
that explains the medication is for you to keep. You do not need to send it back to us.)
Rule 63N-1
HS 001
Revised August 2007
Page 1 of 1