DJJ Form HS002 "Authority for Evaluation and Treatment (Aet)" - Florida

What Is DJJ Form HS002?

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 February 1, 2010;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS002 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 HS002 "Authority for Evaluation and Treatment (Aet)" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AUTHORITY FOR EVALUATION AND TREATMENT (AET)
N
YOUTH: ___________________________________________________________________
AME OF
DJJID #: ______________________________ MEDICAID #: ________________________________
(
A
)
S APPLICABLE
I, ________________________________________,
__________________________________________
THE PARENT OF
OR I, ________________________________________,
____________________________________
AS THE GUARDIAN OF
(“
”)
, “
D
J
J
,
(
MY CHILD
DO
HEREBY
APPOINT
THE
EPARTMENT OF
UVENILE
USTICE
OR ITS AUTHORIZED AGENT
COLLECTIVELY
THE
”),
D
. I
D
EPARTMENT
AS MY REPRESENTATIVE FOR THE PURPOSES SET OUT IN THIS DOCUMENT
AUTHORIZE THE
EPARTMENT TO MAKE THE
,
.
I
DECISIONS CONCERNING MY CHILD
S ROUTINE PHYSICAL AND MENTAL HEALTH TREATMENT
AS DESCRIBED IN THIS DOCUMENT
18. A
UNDERSTAND THAT THIS DOCUMENT APPLIES ONLY UNTIL MY CHILD REACHES THE AGE OF
T THAT TIME MY CHILD WILL CONSENT FOR
/
.
TREATMENT FOR HIS
HER SELF
A LETTER OF GUARDIAN SHOULD BE PRESENTED FOR CLAIM OF GUARDIAN TO YOUTH
S
: _________________________ C
: __________________________ D
: __________________________
TATE
OUNTY
ATE
T
:
HIS AUTHORITY IS LIMITED BY ME AS FOLLOWS
Q
T
UALITY OF
REATMENT
A)
My child will be examined and medically treated only by persons who are properly qualified to perform such examinations
and provide such treatment with exception to defined circumstances as stated herein.
B)
Any treatment authorized by the Department must be recommended by a person licensed in Florida and permitted under
Florida law to make such a recommendation.
C)
Any treatment authorized by the Department must be recommended in accordance with the medical or mental health
standards in the community where the treatment will take place.
T
D
:
HE
EPARTMENT MAY AUTHORIZE THE FOLLOWING ON MY BEHALF
W
A
C
HAT THIS
UTHORITY
OVERS
1.
Physical examinations of my child conducted in accordance with the usual accepted medical standards of the community.
These examinations may include:
a)
Determining whether my child is currently suffering from any illness or disease or has any problems that require
medical treatment while the Department has the youth in its physical custody.
b)
Obtaining a complete medical and mental health history from my child, including information about past illnesses,
hospitalizations, etc.
c)
Testing for drug and/or alcohol abuse.
d)
Blood, urine, tuberculosis and other laboratory tests that may be done as part of a complete physical examination.
e)
Examining my child for any dental problems and providing emergency dental care and treatment.
Testing my child’s vision and hearing.
f)
g)
Gynecological examination.
2.
Give permissions to a licensed health care provider to give my child additional tests that he or she thinks are necessary
as a result of a physical examination.
3.
Obtain necessary medical and clinical treatment for any illness or disease that my child has now or develops while he/she
is in the Department’s facility or program.
4.
Regarding mental health or emotional illnesses that my child now has or develops while in the custody of a Department
facility, the Department may arrange for, make available and facilitate mental health assessments and treatment with
licensed mental health care providers or mental health facilities, including diagnostic assessment, psychological testing,
and individual, group, and family therapy and/or counseling, except as otherwise provided in this section. This section
shall not be read as authorizing my consent to the commitment of my child to a residential facility licensed under Chapter
393, Florida Statutes (Developmental Disabilities) or Chapter 394, Florida Statutes (mental health), but is acknowledging
commitment under Chapter 985, Florida Statutes. If hospitalization in a mental health facility is recommended, I will be
notified in advance, and will have the opportunity to object if I wish to.
63E-7/63M-2
HS 002
REV. 02/10
P
1
3
AGE
OF
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AUTHORITY FOR EVALUATION AND TREATMENT (AET)
N
YOUTH: ___________________________________________________________________
AME OF
DJJID #: ______________________________ MEDICAID #: ________________________________
(
A
)
S APPLICABLE
I, ________________________________________,
__________________________________________
THE PARENT OF
OR I, ________________________________________,
____________________________________
AS THE GUARDIAN OF
(“
”)
, “
D
J
J
,
(
MY CHILD
DO
HEREBY
APPOINT
THE
EPARTMENT OF
UVENILE
USTICE
OR ITS AUTHORIZED AGENT
COLLECTIVELY
THE
”),
D
. I
D
EPARTMENT
AS MY REPRESENTATIVE FOR THE PURPOSES SET OUT IN THIS DOCUMENT
AUTHORIZE THE
EPARTMENT TO MAKE THE
,
.
I
DECISIONS CONCERNING MY CHILD
S ROUTINE PHYSICAL AND MENTAL HEALTH TREATMENT
AS DESCRIBED IN THIS DOCUMENT
18. A
UNDERSTAND THAT THIS DOCUMENT APPLIES ONLY UNTIL MY CHILD REACHES THE AGE OF
T THAT TIME MY CHILD WILL CONSENT FOR
/
.
TREATMENT FOR HIS
HER SELF
A LETTER OF GUARDIAN SHOULD BE PRESENTED FOR CLAIM OF GUARDIAN TO YOUTH
S
: _________________________ C
: __________________________ D
: __________________________
TATE
OUNTY
ATE
T
:
HIS AUTHORITY IS LIMITED BY ME AS FOLLOWS
Q
T
UALITY OF
REATMENT
A)
My child will be examined and medically treated only by persons who are properly qualified to perform such examinations
and provide such treatment with exception to defined circumstances as stated herein.
B)
Any treatment authorized by the Department must be recommended by a person licensed in Florida and permitted under
Florida law to make such a recommendation.
C)
Any treatment authorized by the Department must be recommended in accordance with the medical or mental health
standards in the community where the treatment will take place.
T
D
:
HE
EPARTMENT MAY AUTHORIZE THE FOLLOWING ON MY BEHALF
W
A
C
HAT THIS
UTHORITY
OVERS
1.
Physical examinations of my child conducted in accordance with the usual accepted medical standards of the community.
These examinations may include:
a)
Determining whether my child is currently suffering from any illness or disease or has any problems that require
medical treatment while the Department has the youth in its physical custody.
b)
Obtaining a complete medical and mental health history from my child, including information about past illnesses,
hospitalizations, etc.
c)
Testing for drug and/or alcohol abuse.
d)
Blood, urine, tuberculosis and other laboratory tests that may be done as part of a complete physical examination.
e)
Examining my child for any dental problems and providing emergency dental care and treatment.
Testing my child’s vision and hearing.
f)
g)
Gynecological examination.
2.
Give permissions to a licensed health care provider to give my child additional tests that he or she thinks are necessary
as a result of a physical examination.
3.
Obtain necessary medical and clinical treatment for any illness or disease that my child has now or develops while he/she
is in the Department’s facility or program.
4.
Regarding mental health or emotional illnesses that my child now has or develops while in the custody of a Department
facility, the Department may arrange for, make available and facilitate mental health assessments and treatment with
licensed mental health care providers or mental health facilities, including diagnostic assessment, psychological testing,
and individual, group, and family therapy and/or counseling, except as otherwise provided in this section. This section
shall not be read as authorizing my consent to the commitment of my child to a residential facility licensed under Chapter
393, Florida Statutes (Developmental Disabilities) or Chapter 394, Florida Statutes (mental health), but is acknowledging
commitment under Chapter 985, Florida Statutes. If hospitalization in a mental health facility is recommended, I will be
notified in advance, and will have the opportunity to object if I wish to.
63E-7/63M-2
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AGE
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5.
Obtain prescription medications that have been ordered for my child.
If a new prescription medication has been
recommended or started for my child, or a medication my child was currently receiving has been ordered to be stopped,
or if there is a significant change in the dosage of a medication my child was/is receiving, attempts will be made to
contact me by telephone prior to making any of these changes, unless it is felt necessary to start the medication
immediately. Notices of medication changes will be sent to me at the address I have provided in this document. I
understand that if my address or mailing address changes, I must contact my child’s Juvenile Probation Officer and the
facility where my youth is detained or residentially committed and inform them of the address change.
6.
I understand that I can object to medication changes by calling the facility and speaking to the person listed on the notice.
I further understand that I should also object in writing to the facility listed on the notice sent to me.
7.
Regarding prescription medications for mental or emotional problems that may be ordered or changed, I understand that
reasonable attempts will be made to contact me verbally/by telephone prior to making the changes in order to explain the
medications and that a detailed notice about these medications will also be sent to me. I understand that I am to sign a
permission form and mail it back to the facility.
8.
Regarding vaccinations/immunizations, the Department may provide the standard vaccinations, if my child has not had
them and/or if they are not up to date and/or if they are required to attend school in Florida, such as for tetanus, measles,
polio, and Hepatitis B and if I have been provided the necessary information about the immunization(s) and have
provided my written consent. The Department may authorize and provide flu shots when recommended by a licensed
health care provider if I have been provided the necessary information about the immunization and have provided my
written consent. If I have been provided with the Vaccination Information Sheets at the time of this Consent, this form will
serve as my permission for administration of the vaccines. Otherwise, I will be notified in advance of administration of
these vaccinations and asked for my permission prior to giving them to my child.
9.
I understand that my child may be assisted with the self-administration of routine medications, (depending on the DJJ
facility), by trained/qualified staff who are not health care professionals but will provide these medications based on
procedures that have been approved by the physician who provides oversight to the program and/or provides care to the
youth.
10.
I authorize licensed health care and non-health care staff members to provide Acetaminophen (Tylenol), Ibuprophen
(Motrin), anti-indigestion medications (e.g. Pepto Bismol), antacids (i.e., Milk of Magnesia, Maalox), Triple Antibiotic
Ointment and Diphenhydramine (e.g. Benadryl) for the purpose of allergic reactions only. All of these medications shall
be administered in accordance with the manufacturer’s recommended dosage, to my child for minor physical complaints.
I understand that my child will receive a medical evaluation for minor complaints that are unrelieved by these over-the-
counter medications. I understand that all other over-the-counter medications will be provided pursuant to a Physician’s
approval.
ACCESS TO RECORDS. The Department shall have access to all records of whatever nature concerning the mental
11.
and physical health of my child, to the same extent that I have would have access to them. I understand that my child
may be seen by multiple health care providers, including those that see my child at the facility and those to whom my
child is taken for treatment. To that end, I direct that any and all health care providers, whether involved in mental or
physical health care, shall provide all records to which I would be entitled concerning my child to the Department at the
request of the Department and/or its authorized agents. These records shall include, but not be limited to, records of any
and all past evaluations, assessments and/or treatment of my child, and any and all past prescriptions ordered for my
child. These records also include any evaluations, assessments, and/or treatments of my child provided in the future,
while my child is in the custody of the Department. It is my intent that this document acts as my consent and release
of these records to the Department and/or its authorized agents.
W
T
A
D
N
C
HAT
HIS
UTHORITY
OES
OT
OVER
1.
I understand this Authority applies only when my child is staying 24 hours a day at a facility run by or supervised by the
Department. I am responsible for my child’s health care in any other circumstance. If my child is in a facility-based non-
residential program run by or supervised by the Department, it also gives the Department authority to (a) administer
prescription medications that I bring to the program, and (b) provide any emergency treatment. I understand that I am
responsible for my child’s health care in any other circumstances.
2.
I understand that I cannot choose the physician or other health care provider that will treat my child. The Department has
the right to choose the health care provider as long as the person is properly qualified in Florida. However, in certain
instances, I can ask the Department to utilize my child’s usual provider, particularly if this is convenient for the facility, and
the provider agrees to do so.
3.
I can refuse to sign this document. I can limit the scope of this document by advising the Department in writing of specific
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AGE
OF
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
procedures I will not authorize. In addition, I can take back the permission that I have given in this document at any time
either in part or completely, by calling or writing the facility where my child is located or the person who is providing the
care.
4.
I understand that if I refuse to sign this document or if I take back the permission granted by it, the Department has the right to ask a
court order to give the Department permission to provide treatment. I will have an opportunity to present my concerns to the Judge
before he or she decides about my child’s care.
The Department will keep me advised of my child’s mental and physical health status when warranted. Notices will be
5.
sent to me at the address I have listed in this document. It is my responsibility to inform the Department of any change in
the address.
6.
I understand that if my child requires substance abuse treatment that my child must provide his or her consent to
substance abuse treatment and that my signature on this document does not provide authorization for this treatment.
A
CKNOWLEDGEMENTS
I declare that I have read and understand the terms of this document. All questions I have concerning the powers I
have given the Department in this document have been answered to my satisfaction. No one has made any
threats in order to get me to sign this document.
I
NITIALS
I am consenting to necessary vaccinations.
I have received the following Vaccine Information Sheet (s):
_______________________________________________________________________ (list here)
I am refusing Vaccinations due to religious reasons. I understand I must now complete “The Religious
Exemption From Immunization” Form (at the County Health Department) and have it signed and
authorized by their Administrator and submit a copy to the Department of Juvenile Justice.
I am refusing Vaccinations due to medical reasons. I understand I must now submit a Physician’s
statement to the Department stating why the vaccinations are contraindicated.
I am refusing to sign the Authority for Evaluation and Treatment form.
_________________________________________________________
Reason:
D
_________________________
________________________________, 20____.
ATED THIS
DAY OF
___________________________________________
_____________________________________________
W
: DJJ R
(S
)
P
G
(S
)
ITNESSED BY
EPRESENTATIVE
IGNATURE
ARENT OR
UARDIAN
IGNATURE
______________________________________
___________________________________________
DJJ R
(P
)
P
G
(P
)
EPRESENTATIVE
RINTED
ARENT OR
UARDIAN
RINTED
A
: _____________________________________
DDRESS
: ___________________________ (
)
PHONE NUMBER
HOME
: _____________________________(
)
PHONE NUMBER
CELL
: ____________________________(
)
PHONE NUMBER
WORK
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