DJJ Form HS057 "Limited Consent for Evaluation and Treatment" - Florida

What Is DJJ Form HS057?

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 December 1, 2013;
  • 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 printable version of DJJ Form HS057 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 HS057 "Limited Consent for Evaluation and Treatment" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
LIMITED CONSENT FOR EVALUATION AND TREATMENT
N
YOUTH: ___________________________________________________________________
AME OF
DJJID #: ______________________________ MEDICAID #: ________________________________
(
A
)
S APPLICABLE
T
:
HIS AUTHORITY IS LIMITED AS FOLLOWS
Q
T
UALITY OF
REATMENT
A)
The 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.
W
C
C
HAT THIS
ONSENT
OVERS
1.
Physical examinations conducted in accordance with the usual accepted medical standards of the community. These
examinations may include:
a)
Determining whether the 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 the 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 the child for any dental problems, and providing emergency dental care and treatment.
Testing the child’s vision and hearing.
f)
g)
Gynecological examination.
2.
Give permissions to a licensed health care provider to give the 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 the child has now or develops while he/she
is in the Department’s facility.
4.
Regarding mental health or emotional illnesses that the 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.
5.
Obtain prescription medications that are currently prescribed, excluding psychotropic medications, for the child.
6.
Regarding vaccinations/immunizations, the Department may provide the standard vaccinations, if the 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 after review of the necessary information about the immunization(s).
7.
I authorize licensed health care and non-health care staff members to provide antipyretics, non-steroidal anti-
inflammatory medications (excluding Aspirin), anti-indigestion medications, antacids, Triple Antibiotic Ointment and
antihistamines for the purpose of allergic reactions only. All of these medications shall be administered in accordance
with the manufacturer’s recommended dosage, to the child for minor physical complaints. I understand that the 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.
8.
ACCESS TO RECORDS. The Department shall have access to all records of whatever nature concerning the mental
and physical health of the child. I direct that any and all health care providers, whether involved in mental or physical
health care, shall provide all records concerning the child to the Department at the request of the Department and/or its
authorized agents. These records also include any evaluations, assessments, and/or treatments of the child provided in
the future, while the child is in the custody of the Department. It is my intent that this document acts as the consent
and release of these records to the Department and/or its authorized agents.
HS 057
63M-2
Page 1 of 3
12/13
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
LIMITED CONSENT FOR EVALUATION AND TREATMENT
N
YOUTH: ___________________________________________________________________
AME OF
DJJID #: ______________________________ MEDICAID #: ________________________________
(
A
)
S APPLICABLE
T
:
HIS AUTHORITY IS LIMITED AS FOLLOWS
Q
T
UALITY OF
REATMENT
A)
The 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.
W
C
C
HAT THIS
ONSENT
OVERS
1.
Physical examinations conducted in accordance with the usual accepted medical standards of the community. These
examinations may include:
a)
Determining whether the 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 the 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 the child for any dental problems, and providing emergency dental care and treatment.
Testing the child’s vision and hearing.
f)
g)
Gynecological examination.
2.
Give permissions to a licensed health care provider to give the 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 the child has now or develops while he/she
is in the Department’s facility.
4.
Regarding mental health or emotional illnesses that the 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.
5.
Obtain prescription medications that are currently prescribed, excluding psychotropic medications, for the child.
6.
Regarding vaccinations/immunizations, the Department may provide the standard vaccinations, if the 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 after review of the necessary information about the immunization(s).
7.
I authorize licensed health care and non-health care staff members to provide antipyretics, non-steroidal anti-
inflammatory medications (excluding Aspirin), anti-indigestion medications, antacids, Triple Antibiotic Ointment and
antihistamines for the purpose of allergic reactions only. All of these medications shall be administered in accordance
with the manufacturer’s recommended dosage, to the child for minor physical complaints. I understand that the 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.
8.
ACCESS TO RECORDS. The Department shall have access to all records of whatever nature concerning the mental
and physical health of the child. I direct that any and all health care providers, whether involved in mental or physical
health care, shall provide all records concerning the child to the Department at the request of the Department and/or its
authorized agents. These records also include any evaluations, assessments, and/or treatments of the child provided in
the future, while the child is in the custody of the Department. It is my intent that this document acts as the consent
and release of these records to the Department and/or its authorized agents.
HS 057
63M-2
Page 1 of 3
12/13
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
W
T
C
D
N
C
HAT
HIS
ONSENT
OES
OT
OVER
1.
I understand this Consent applies only when the child is staying 24 hours a day at a Department detention facility.
2.
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, the Department may be able to utilize the child’s usual provider, particularly if this is
convenient for the facility, and the provider agrees to do so.
3.
This signed consent does not provide authorization for substance abuse treatment. The child must provide his or her
consent to this treatment.
4.
This signed consent does not authorize the provision of psychotropic medications.
A
CKNOWLEDGEMENTS
I am consenting to necessary vaccinations. I have received the following Vaccine Information
Sheet(s) :____________________________________________________________(list here)
D
_________________________
________________________________, 20____.
ATED THIS
DAY OF
F
NOT
:
OR YOUTH
IN THE DEPENDENCY SYSTEM
T
. T
JPO
A
HE PARENT OR GUARDIAN COULD NOT BE CONTACTED AFTER A DILIGENT SEARCH
HE
SHALL ATTACH AN
FFIDAVIT OF
D
E
(HS 056),
F
S
A
. A
A
ILIGENT
FFORT
AND THE
ACILITY
UPERINTENDENT OR
SSISTANT MAY SIGN
FULL
UTHORITY FOR
E
T
(HS 002)
,
L
VALUATION AND
REATMENT
SHALL BE OBTAINED AS SOON AS POSSIBLE
WHICH SHALL SUPERSEDE THIS
IMITED
C
.
ONSENT
_______________________________________
_____________________________________________
D
F
S
(S
)
W
: DJJ R
(S
)
ETENTION
ACILITY
UPERINTENDENT
IGNATURE
ITNESSED BY
EPRESENTATIVE
IGNATURE
_______________________________________
____________________________________________
D
F
S
(P
)
DJJ R
(P
)
ETENTION
ACILITY
UPERINTENDENT
RINTED
EPRESENTATIVE
RINTED
F
:
OR YOUTH IN THE DEPENDENCY SYSTEM WHO REMAIN IN THE HOME OF PARENT OR GUARDIAN
W
,
JPO
HERE THE PARENT OR GUARDIAN COULD NOT BE CONTACTED AFTER A DILIGENT SEARCH
THE
SHALL ATTACH AN
A
D
E
(HS 056),
F
S
A
.
FFIDAVIT OF
ILIGENT
FFORT
AND THE
ACILITY
UPERINTENDENT OR
SSISTANT MAY SIGN
_________________________________________
_____________________________________________
P
G
(S
)
W
: DJJ R
(S
)
ARENT OR
UARDIAN
IGNATURE
ITNESSED BY
EPRESENTATIVE
IGNATURE
________________________________
______
____________________________________________
P
G
(P
)
DJJ R
(P
)
ARENT OR
UARDIAN
RINTED
EPRESENTATIVE
RINTED
OR
________________________________________
D
F
S
(S
)
ETENTION
ACILITY
UPERINTENDENT
IGNATURE
________________________________________
ASDFASDFAS
D
F
S
(P
)
ETENTION
ACILITY
UPERINTENDENT
RINTED
____________________________________________
DJJ R
(P
)
EPRESENTATIVE
RINTED
HS 057
63M-2
Page 2 of 3
12/13
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
F
-
-
:
OR YOUTH IN THE DEPENDENCY SYSTEM WHO ARE IN OUT
OF
HOME CARE
T
JPO
D
C
F
HE
SHALL CONTACT THE
EPARTMENT OF
HILDREN AND
AMILIES OR ITS CONTRACTED SERVICE PROVIDER TO OBTAIN
,
D
C
F
,
-
-
,
LIMITED CONSENT FROM THE PARENT
THE
EPARTMENT OF
HILDREN AND
AMILIES
OR THE OUT
OF
HOME CAREGIVER
AS
C
.
REQUIRED BY THE
OURT
S ORDER OF PLACEMENT
_________________________________________
_____________________________________________
P
G
(S
)
W
: DCF R
(S
)
ARENT OR
UARDIAN
IGNATURE
ITNESSED BY
EPRESENTATIVE
IGNATURE
________________________________
______
____________________________________________
P
G
(P
)
DCF R
(P
)
ARENT OR
UARDIAN
RINTED
EPRESENTATIVE
RINTED
OR
___________________________________________
DCF C
M
. / C
P
(S
)
ASE
GR
ONTRACTED
ROVIDER
IGNATURE
___________________________________________
DCF C
M
. / C
P
(P
)
ASE
GR
ONTRACTED
ROVIDER
RINTED
OR
________________________________________
O
-
-
C
(S
)
UT
OF
HOME
AREGIVER
IGNATURE
________________________________________
O
-
-
C
(P
)
UT
OF
HOME
AREGIVER
RINTED
____________________________________________
DJJ R
(P
)
EPRESENTATIVE
RINTED
F
:
OR YOUTH IN THE DEPENDENCY SYSTEM WITH A TERMINATION OF PARENTAL RIGHTS
___________________________________________
___________________________________________
DCF C
M
. / C
P
(S
)
W
: DJJ R
(S
)
ASE
GR
ONTRACTED
ROVIDER
IGNATURE
ITNESSED BY
EPRESENTATIVE
IGNATURE
________________________________ ___ ______
___________________________________________
DCF C
M
. / C
P
(P
)
DJJ R
(P
)
ASE
GR
ONTRACTED
ROVIDER
RINTED
EPRESENTATIVE
RINTED
HS 057
63M-2
Page 3 of 3
12/13
Page of 3