Form JV-220(B) "Physician's Request to Continue Medication - Attachment" - California

What Is Form JV-220(B)?

This is a legal form that was released by the California Courts - 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 Courts;
  • 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(B) by clicking the link below or browse more documents and templates provided by the California Courts.

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Download Form JV-220(B) "Physician's Request to Continue Medication - Attachment" - California

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Case Number:
Physician’s Request to Continue
JV-220(B)
Medication—Attachment
This form must be completed and signed by the prescribing physician. Read form JV-217-INFO, Guide to Psychotropic
Medication Forms, for more information about the required forms and the application process.
Information about the child (name):
1
Date of birth:
Current height:
Current weight:
Gender:
Ethnicity:
Fill out this form only if both boxes below are checked. If you cannot check both boxes, fill out form JV-220(A).
2
a.
This is a request to continue the same psychotropic medication and maximum dosage that the child is
currently taking.
b.
This is the same prescribing physician who completed the most recent form JV-220(A).
3
Prescribing physician:
a.
Name:
License number:
b.
Address:
c.
Phone numbers:
d.
Medical specialty of prescribing physician:
Child/adolescent psychiatry
General psychiatry
Family practice/GP
Pediatrics
Other (specify):
4
This request is based on a face-to-face clinical evaluation of the child by:
a.
The prescribing physician on (date):
b.
Other (provide name, professional status, and date of evaluation):
5
Information about the child was provided to the prescribing physician by (check all that apply):
Child
Caregiver
Teacher
Social worker
Probation officer
Parent
Public health nurse
Tribe
Records (specify):
Other (specify):
6
Provide to the court your assessment of the child’s overall mental health.
Judicial Council of California, www.courts.ca.gov
Physician’s Request to Continue
JV-220(B),
Page 1 of 4
Revised January 1, 2018, Alternative Mandatory Form
instead of JV-220(A) for renewal under rule 5.640(c)(7)
Medication—Attachment
Welfare and Institutions Code, §§ 369.5, 739.5
California Rules of Court, rule 5.640
Case Number:
Physician’s Request to Continue
JV-220(B)
Medication—Attachment
This form must be completed and signed by the prescribing physician. Read form JV-217-INFO, Guide to Psychotropic
Medication Forms, for more information about the required forms and the application process.
Information about the child (name):
1
Date of birth:
Current height:
Current weight:
Gender:
Ethnicity:
Fill out this form only if both boxes below are checked. If you cannot check both boxes, fill out form JV-220(A).
2
a.
This is a request to continue the same psychotropic medication and maximum dosage that the child is
currently taking.
b.
This is the same prescribing physician who completed the most recent form JV-220(A).
3
Prescribing physician:
a.
Name:
License number:
b.
Address:
c.
Phone numbers:
d.
Medical specialty of prescribing physician:
Child/adolescent psychiatry
General psychiatry
Family practice/GP
Pediatrics
Other (specify):
4
This request is based on a face-to-face clinical evaluation of the child by:
a.
The prescribing physician on (date):
b.
Other (provide name, professional status, and date of evaluation):
5
Information about the child was provided to the prescribing physician by (check all that apply):
Child
Caregiver
Teacher
Social worker
Probation officer
Parent
Public health nurse
Tribe
Records (specify):
Other (specify):
6
Provide to the court your assessment of the child’s overall mental health.
Judicial Council of California, www.courts.ca.gov
Physician’s Request to Continue
JV-220(B),
Page 1 of 4
Revised January 1, 2018, Alternative Mandatory Form
instead of JV-220(A) for renewal under rule 5.640(c)(7)
Medication—Attachment
Welfare and Institutions Code, §§ 369.5, 739.5
California Rules of Court, rule 5.640
Case Number:
Child’s name:
Describe the child’s response to any current psychotropic medication.
a.
7
Describe the symptoms not alleviated or ameliorated by other current or past treatment efforts.
b.
8
a.
Have nonpharmacological treatment alternatives to the proposed medications been tried in the last six months?
Yes
No
I don’t know.
If yes, describe the treatment and the child’s response. If no, explain why not.
b.
9
Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):
10
Relevant medical history (describe, specifying significant medical conditions, all current nonpsychotropic
medications, date of last physical examination, and any recent abnormal laboratory results)
:
Rev. January 1, 2018
Physician’s Request to Continue
JV-220(B),
Page 2 of 4
Medication—Attachment
Case Number:
Child’s name:
11
a.
All essential laboratory tests were performed.
All essential laboratory tests were not performed (explain what laboratory tests were not done and why).
b.
12
a.
The child was told in an age-appropriate manner about the recommended medications, the anticipated
benefits, the possible side effects, and that a request to the court for permission to begin and/or continue the
medication will be made and that he or she may oppose the request. The child’s response was:
Agreeable
Not agreeable
Briefly describe child’s response:
b.
The child has not been informed of this request, the recommended medications, their anticipated benefits,
and their possible adverse reactions because:
(1)
The child lacks the capacity to provide a response (explain):
(2)
Other (explain):
Mandatory Information Attached: Significant side effects, warnings/contraindications, drug interactions
13
a.
(including those with continuing psychotropic medication and all nonpsychotropic medication currently taken by
the child), and withdrawal symptoms for each recommended medication are included in the attached material.
b.
The caregiver was informed of the mandatory information, which is attached.
The caregiver’s response was
agreeable
other (explain):
c.
14
Additional information regarding medication treatment plan and follow-up:
Rev. January 1, 2018
Physician’s Request to Continue
JV-220(B),
Page 3 of 4
Medication—Attachment
Case Number:
Child’s name:
15
Therapeutic services, other than medication, in which the child is enrolled in or is recommended to participate
during the next six months (check all that apply; include frequency for therapy on blank line):
a.
Group therapy:
Individual therapy:
b.
c.
Milieu therapy (explain):
Therapeutic Behavioral Services (TBS):
d.
Therapy for children on the autism spectrum:
e.
Art therapy:
Cognitive behavioral therapy (CBT):
f.
g.
h.
Wraparound services:
American Indian/Alaska Native healing and cultural traditions:
i.
Speech therapy:
j.
In Home Behavioral Services (IHBS):
k.
Other modality (explain):
l.
16
List all psychotropic medications currently administered that you propose to continue.
Administration schedule
Maximum
Treatment
Medication name (generic/brand) and
• Initial and target schedule for new medication
total
duration*
symptoms targeted by each medication’s
• Current schedule for continuing medication
mg/day
6-month
anticipated benefit to child
• Provide mg/dose and # of doses/day
maximum
• If PRN, provide conditions and parameters for use
Med:
Class:
Targets:
Med:
Class:
Targets:
Med:
Class:
Targets:
Med:
Class:
Targets:
*Authorization to administer the medication is limited to this time frame or six months from the date the order is issued, whichever occurs first.
17
Other information about the prescribed medication that you want the court to know (e.g., reasons for prescribing
more than one medication in a class, prescribing outside the approved range, or prescribing medication not approved
for a child of this age):
Date:
Type or print name of prescribing physician
Signature of prescribing physician
Rev. January 1, 2018
JV-220(B),
Physician’s Request to Continue
Page 4 of 4
Medication—Attachment
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