Form JV-220 "Application for Psychotropic Medication" - California

What Is Form JV-220?

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

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the California Superior Court;
  • 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 JV-220 by clicking the link below or browse more documents and templates provided by the California Superior Court.

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Download Form JV-220 "Application for Psychotropic Medication" - California

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Application for
Clerk stamps date here when form is filed.
JV-220
Psychotropic Medication
A completed and signed Physician’s Statement—Attachment
(form JV-220(A)), or Physician’s Request to Continue Medication—
Attachment (form JV-220(B)) with all its attachments must be attached to this
form before it is filed with the court. Read form JV-217-INFO, Guide to
Psychotropic Medication Forms, for more information about the required
forms and the application process.
1
Information about where the child lives:
with a relative
in a foster home
a. The child lives
Fill in court name and street address:
with a nonrelative extended family member
Superior Court of California, County of
in a group home, level
at a juvenile custodial facility
in a short-term residential therapeutic program
other (specify):
b. If applicable, the name of the facility where the child lives:
Fill in child's name and date of birth:
c. Contact information for a responsible adult where the child lives:
Child's Name:
(1)
Name:
Date of Birth:
(2)
Phone:
Court fills in case number when form is filed.
d. The child has lived at the placement in (a) since (insert date):
Case Number:
2
Information about the child’s current location:
a.
1
The child remains at the location identified in
.
b.
The child is currently staying in:
a psychiatric hospital (name):
(1)
a juvenile hall (name):
(2)
other (specify):
(3)
social worker
probation officer
3
Child’s
a. Name:
Address:
b.
c.
Phone:
E-mail:
Fax:
Number of pages attached:
4
Date:
Signature
Type or print name of person completing this form
Child welfare services staff (sign above, complete items
1
, and sign on page 4)
13
Probation department staff (sign above, complete items
1
, and sign on page 4)
13
Medical office staff (sign above)
Caregiver (sign above)
Prescribing physician (sign on page 6 of JV-220(A)
or page 4 of JV-220(B))
JV-220,
Judicial Council of California, www.courts.ca.gov
Application for
Page 1 of 4
Revised January 1, 2018, Mandatory Form
Welfare and Institutions Code, §§ 369.5, 739.5
Psychotropic Medication
California Rules of Court, rule 5.640
Application for
Clerk stamps date here when form is filed.
JV-220
Psychotropic Medication
A completed and signed Physician’s Statement—Attachment
(form JV-220(A)), or Physician’s Request to Continue Medication—
Attachment (form JV-220(B)) with all its attachments must be attached to this
form before it is filed with the court. Read form JV-217-INFO, Guide to
Psychotropic Medication Forms, for more information about the required
forms and the application process.
1
Information about where the child lives:
with a relative
in a foster home
a. The child lives
Fill in court name and street address:
with a nonrelative extended family member
Superior Court of California, County of
in a group home, level
at a juvenile custodial facility
in a short-term residential therapeutic program
other (specify):
b. If applicable, the name of the facility where the child lives:
Fill in child's name and date of birth:
c. Contact information for a responsible adult where the child lives:
Child's Name:
(1)
Name:
Date of Birth:
(2)
Phone:
Court fills in case number when form is filed.
d. The child has lived at the placement in (a) since (insert date):
Case Number:
2
Information about the child’s current location:
a.
1
The child remains at the location identified in
.
b.
The child is currently staying in:
a psychiatric hospital (name):
(1)
a juvenile hall (name):
(2)
other (specify):
(3)
social worker
probation officer
3
Child’s
a. Name:
Address:
b.
c.
Phone:
E-mail:
Fax:
Number of pages attached:
4
Date:
Signature
Type or print name of person completing this form
Child welfare services staff (sign above, complete items
1
, and sign on page 4)
13
Probation department staff (sign above, complete items
1
, and sign on page 4)
13
Medical office staff (sign above)
Caregiver (sign above)
Prescribing physician (sign on page 6 of JV-220(A)
or page 4 of JV-220(B))
JV-220,
Judicial Council of California, www.courts.ca.gov
Application for
Page 1 of 4
Revised January 1, 2018, Mandatory Form
Welfare and Institutions Code, §§ 369.5, 739.5
Psychotropic Medication
California Rules of Court, rule 5.640
Case Number:
Child
s name:
If you are the child's social worker or probation officer, you must fill out items 5–13 of this form. If you do not know the
answer to a question, write “I do not know.” If you are not the child’s social worker or probation officer, you do not need
to fill out items 5–13 of this form.
5
Describe if the child has shared feelings about starting to take medication. If this is a request to renew or modify
medication, include what the child reports regarding the benefits and side effects of having taken the medication.
6
The child will provide input on the medication being prescribed (check all that apply):
Through the social worker/probation officer.
b.
Through his or her attorney.
a.
c.
Through his or her CASA.
d.
By filling out form JV-218.
e.
By writing a letter to the judge.
f.
By talking to the judge at a hearing.
g.
Other (specify):
7
Describe what the caregiver reports regarding the child being placed on the medication. If this is a request to renew
or modify medication, include what the caregiver reports regarding the benefits and side effects of having the child
take medication.
8
The caregiver will provide input on the medication being prescribed (check all that apply):
a.
Through the social worker/probation officer.
b.
By filling out form JV-219.
By writing a letter to the judge.
c.
By talking to the judge at a hearing.
d.
e.
Other (specify):
9
a.
Is the information provided by the physician on form JV-220(A) at questions 10 and 11 or on form JV-220(B) at
question 8 accurate, to the best of your knowledge?
Yes
No
I do not know
Do you have additional information about mental health treatment alternatives to the proposed medications that
b.
have been used in the last six months?
Yes
No
If yes, explain:
Rev. January 1, 2018
Application for
JV-220,
Page 2 of 4
Psychotropic Medication
Case Number:
Child
s name:
c. Do you have additional information to add about other psychotropic medications that have been tried in the last
9
Yes
No
six months?
If yes, explain:
d. List the psychotropic medications that you know were taken by the child in the past and the reason or reasons
these were stopped, if the reasons are known to you.
Reason for stopping
Medication name (generic or brand)
10
Therapeutic services, other than medication, which the child is enrolled in or is recommended to participate in
during the next six months (check all that apply; include frequency for therapy on blank line):
Group therapy:
Individual therapy:
a.
b.
Milieu therapy (explain):
c.
d.
Therapeutic Behavioral Services (TBS):
Therapy for children on the autism spectrum:
e.
Art therapy:
f.
Cognitive behavioral therapy (CBT):
g.
Wraparound services:
h.
American Indian/Alaska Native healing and cultural traditions:
i.
j.
Speech therapy:
k.
In Home Behavioral Services (IHBS):
Other modality (explain):
l.
11
What other services could benefit or enhance the child’s well-being (for example, sports, art, extracurricular
activities)?
Application for
Rev. January 1, 2018
JV-220,
Page 3 of 4
Psychotropic Medication
Case Number:
Child
s name:
12
What comments, if any, do you have regarding the application? What else do you want the judge to know?
Check here if you need more space for any of the items. Write the item number and additional information here.
13
If you need more space, attach a sheet or sheets of paper.
Date:
}
Type or print name of person completing this form
Signature
Child welfare services staff (sign above)
Probation department staff (sign above)
Rev. January 1, 2018
Application for
JV-220,
Page 4 of 4
Psychotropic Medication
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