Form DCF-465 "Psychotropic Medication Consent Requests" - Connecticut

What Is Form DCF-465?

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 July 1, 2014;
  • 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-465 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-465 "Psychotropic Medication Consent Requests" - Connecticut

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Connecticut Department of Children and Families
PSYCHOTROPIC MEDICATION CONSENT REQUESTS (FAX TO: 1-877-DCF-DRUG)
DCF-465
7/14 (Rev.)
Page 1 of 3
HOW TO USE THIS FORM:
1. This form is to be used for DCF-committed children only.
2. For children on a 96-hour hold or an Order of Temporary Custody or who are committed delinquent
or Voluntary Services Program, DCF does not have the authority to give consent. Please contact
the DCF Social Worker to find out who the consenting guardian is (generally the parent).
3. When the child is DCF-committed, please specify the person to receive the consent decision and
the fax number or e-mail address to which the decision is to be sent.
4. Every time a child changes providers or settings, a new DCF-465 must be submitted to the
Centralized Medication Consent Unit (CMCU).
5. If the plan is to continue the current psychotropic medication regimen without any changes, the
medications may be given while waiting for the response from the CMCU.
6. In urgent situations after hours for new medications only, see below for how to contact the Careline.
7. For requests to start Lithium, Valproic Acid, Atypical Antipsychotic, Clozapine, and Carbamazepine,
baseline studies must be documented in Section VIII - Monitoring Studies prior to approval.
Weekdays - (Monday through Friday, 8 am to 5 pm)
Fax or e-mail the completed and signed form to the Centralized Medication Consent Unit (CMCU):
FAX to: 1-877-DCF-DRUG (1-877-323-3784) or e-mail to:
getmeds.dcf@ct.gov
CMCU staff will send the response to the fax number or email address the provider identifies on the
form
Designated Area Office staff and the provider will be notified of the decision by CMCU staff
Do not send the DCF-465 to the DCF Area Office Social Worker.
After Hours - For new urgent medications only.
(Monday through Friday after 5 pm, or weekends, state furlough days and state holidays)
Call the DCF Careline at 1-800-842-2288 to notify them of the request; and
Fax or email the DCF-465 to the DCF Careline as arranged during the call.
Medication for Emergency Use is covered by Conn. Gen. Stat. §17a-81.
Emergency use includes those situations in which the physician concludes that the treatment is
necessary to prevent serious harm to the child.
Complete the DCF-465 for emergency-use psychotropic medications within 3 days and send to the
CMCU fax number.
Psychotropic Medication Monitoring Protocols, DCF-Approved Medications and Daily Dosages and Maximum
Daily Dosages are available on the Centralized Medication Consent Unit Website at
http://www.ct.gov/dcf/cwp/view.asp?a=4628&Q=543830
Please contact 860-550-6667 with any questions regarding this process or if you haven't received a call
back or completed response within 2 business days.
Connecticut Department of Children and Families
PSYCHOTROPIC MEDICATION CONSENT REQUESTS (FAX TO: 1-877-DCF-DRUG)
DCF-465
7/14 (Rev.)
Page 1 of 3
HOW TO USE THIS FORM:
1. This form is to be used for DCF-committed children only.
2. For children on a 96-hour hold or an Order of Temporary Custody or who are committed delinquent
or Voluntary Services Program, DCF does not have the authority to give consent. Please contact
the DCF Social Worker to find out who the consenting guardian is (generally the parent).
3. When the child is DCF-committed, please specify the person to receive the consent decision and
the fax number or e-mail address to which the decision is to be sent.
4. Every time a child changes providers or settings, a new DCF-465 must be submitted to the
Centralized Medication Consent Unit (CMCU).
5. If the plan is to continue the current psychotropic medication regimen without any changes, the
medications may be given while waiting for the response from the CMCU.
6. In urgent situations after hours for new medications only, see below for how to contact the Careline.
7. For requests to start Lithium, Valproic Acid, Atypical Antipsychotic, Clozapine, and Carbamazepine,
baseline studies must be documented in Section VIII - Monitoring Studies prior to approval.
Weekdays - (Monday through Friday, 8 am to 5 pm)
Fax or e-mail the completed and signed form to the Centralized Medication Consent Unit (CMCU):
FAX to: 1-877-DCF-DRUG (1-877-323-3784) or e-mail to:
getmeds.dcf@ct.gov
CMCU staff will send the response to the fax number or email address the provider identifies on the
form
Designated Area Office staff and the provider will be notified of the decision by CMCU staff
Do not send the DCF-465 to the DCF Area Office Social Worker.
After Hours - For new urgent medications only.
(Monday through Friday after 5 pm, or weekends, state furlough days and state holidays)
Call the DCF Careline at 1-800-842-2288 to notify them of the request; and
Fax or email the DCF-465 to the DCF Careline as arranged during the call.
Medication for Emergency Use is covered by Conn. Gen. Stat. §17a-81.
Emergency use includes those situations in which the physician concludes that the treatment is
necessary to prevent serious harm to the child.
Complete the DCF-465 for emergency-use psychotropic medications within 3 days and send to the
CMCU fax number.
Psychotropic Medication Monitoring Protocols, DCF-Approved Medications and Daily Dosages and Maximum
Daily Dosages are available on the Centralized Medication Consent Unit Website at
http://www.ct.gov/dcf/cwp/view.asp?a=4628&Q=543830
Please contact 860-550-6667 with any questions regarding this process or if you haven't received a call
back or completed response within 2 business days.
Connecticut Department of Children and Families
PSYCHOTROPIC MEDICATION CONSENT REQUESTS (FAX TO: 1-877-DCF-DRUG)
DCF-465
7/14 (Rev.)
Page 2 of 3
Section I:
Name of Child:
Date of Birth:
Gender:
Prescriber:
Tel # (cell):
Return Response To: FAX #:
E-mail:
Contact Person (if not prescriber):
Tel#:
Section II: Child 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:
Section III: Reason for Psychotropic Medication Request: (Check all that apply)
Dosage Adjustment
Notification of Emergency Use
Request for Non-DCF Approved Medication*
New Medication
Yearly Renewal (required)
Medication Cross Taper
Discontinuation
Continue Current Medication (May continue current medications while awaiting consent from CMCU)
Section IV: Current Medications
Current Psychotropic Medications:
Current Non-Psychotropic Medications
Allergies:
Section V: DSM-V Diagnoses
List Primary Psychiatric Diagnoses
List Primary Medical Diagnoses
Connecticut Department of Children and Families
PSYCHOTROPIC MEDICATION CONSENT REQUESTS (FAX TO: 1-877-DCF-DRUG)
DCF-465
7/14 (Rev.)
Page 3 of 3
Section VI: Clinical Reasons for Request:
Please summarize reason for request:
Section VII: Requested Psychotropic Medication Change*:
Medication/Dose/Range/Route:
Target Symptoms
Cross Taper Plan (timeframe)
Section VIII: Monitoring Studies*
■ Per CMCU Bolded Baseline Study Guidelines Are Mandatory ■ Document Abnormal Results Below
Date Completed:
BP:
Pulse:
HT:
WT:
BMI%:
Date Completed:
AIMS:
Normal
Abnormal
Results (if abnormal)
Date Completed:
Labs:
Normal
Abnormal
Results (if abnormal)
Date Completed:
Drug Levels:
Lithium
VPA
Tegretol
Other
Date Completed:
EKG (most recent)
Normal
Abnormal
Results (if abnormal)
Date Completed:
Cardiac History
Normal
Abnormal
Unknown
Date Completed:
*Baseline Lithium
CBC
BUN/Cr
Sodium
TSH
Potassium
Date Completed:
*Baseline Valproic Acid:
CBC
AST/ALT
Date Completed:
*Baseline Atypical Antipsychotic
AIMS
AST/ALT
Fasting lipids
Fasting Glucose
Date Completed:
*Baseline Clozapine
CBC
Fasting Lipids
Fasting Glucose
Results (if abnormal)
Date Completed:
*Baseline Carbamazepine
CBC
AST/ALT
Sodium
EKG
Pregnancy Test Results:
* Document Abnormal Results:
 
See http://www.ct.gov/dcf for monitoring guidelines, list of DCF‐approved psychotropic meds and max dosages
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