Form DCF-465A "Notification - Discontinuation of a Psychotropic Medication" - Connecticut

What Is Form DCF-465A?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • 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 Form DCF-465A by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-465A "Notification - Discontinuation of a Psychotropic Medication" - Connecticut

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Connecticut Department of Children and Families
NOTIFICATION: Discontinuation Of A Psychotropic Medication (FAX TO: 1-877-DCF-DRUG)
DCF-465A
12/12 (Rev.)
Page 1 of 1
Date:
Time:
Name of Child:
Date of Birth:
Gender:
Prescriber:
Tel # (cell):
Return Response To: FAX #:
E-mail:
Contact Person (if not prescriber):
Tel#:
Child’s Current Placement:
Hospital
Subacute/PRT
Safe Home/Shelter
Foster Home
Detention/CJTS
Residential
Group Home
Name of Treatment Setting:
Date Last Seen by Prescriber:
Initial Assessment
Follow Up Assessment
Next Appointment:
Reason for Discontinuation (Include adverse
Medications to be Discontinued
Current dosage and frequency
reactions, efficacy, other reasons)
NOTE: If child has had an allergic or adverse reaction to the medication, also complete and send a
DCF-465B Suspected Adverse Drug Reaction Reporting Form.
You will not receive a written response to this notification. We ask that you include contact
information in case we need additional information.
Provider Signature:
Date:
FAX TO: 1-877-DCF-DRUG or E-mail to
getmeds@ct.gov
Connecticut Department of Children and Families
NOTIFICATION: Discontinuation Of A Psychotropic Medication (FAX TO: 1-877-DCF-DRUG)
DCF-465A
12/12 (Rev.)
Page 1 of 1
Date:
Time:
Name of Child:
Date of Birth:
Gender:
Prescriber:
Tel # (cell):
Return Response To: FAX #:
E-mail:
Contact Person (if not prescriber):
Tel#:
Child’s Current Placement:
Hospital
Subacute/PRT
Safe Home/Shelter
Foster Home
Detention/CJTS
Residential
Group Home
Name of Treatment Setting:
Date Last Seen by Prescriber:
Initial Assessment
Follow Up Assessment
Next Appointment:
Reason for Discontinuation (Include adverse
Medications to be Discontinued
Current dosage and frequency
reactions, efficacy, other reasons)
NOTE: If child has had an allergic or adverse reaction to the medication, also complete and send a
DCF-465B Suspected Adverse Drug Reaction Reporting Form.
You will not receive a written response to this notification. We ask that you include contact
information in case we need additional information.
Provider Signature:
Date:
FAX TO: 1-877-DCF-DRUG or E-mail to
getmeds@ct.gov