Form JV-220(A) "Physician's Statement - Attachment" - California

What Is Form JV-220(A)?

This is a legal form that was released by the California Judicial Branch - 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 Judicial Branch;
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  • Fill out the form in our online filing application.

Download a fillable version of Form JV-220(A) by clicking the link below or browse more documents and templates provided by the California Judicial Branch.

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Case Number:
Physician’s Statement—
JV-220(A)
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:
2
Type of request:
a.
An initial request to administer psychotropic medication to this child
b.
A request to start a new medication or to increase the maximum dose of a previously approved medication
A request to continue psychotropic medication the child is currently taking
c.
3
This application is made during an emergency situation as defined in California Rules of Court, rule 5.640(i).
The emergency circumstances requiring the temporary administration of psychotropic medication pending the
court’s decision on this application are:
4
Prescribing physician:
Name:
License number:
a.
b.
Address:
c.
Phone numbers:
d.
Medical specialty of prescribing physician:
Child/adolescent psychiatry
General psychiatry
Family practice/GP
Pediatrics
Other (specify):
How long have you been treating the child?
years
months
days
e.
In what capacity have you been treating the child (e.g., treating psychiatrist, treating pediatrician)?
f.
5
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):
6 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):
JV-220(A),
Judicial Council of California, www.courts.ca.gov
Physician’s Statement—Attachment
Page 1 of 6
Revised January 1, 2018, Mandatory Form
Welfare and Institutions Code, §§ 369.5; 739.5
California Rules of Court, rule 5.640
Case Number:
Physician’s Statement—
JV-220(A)
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:
2
Type of request:
a.
An initial request to administer psychotropic medication to this child
b.
A request to start a new medication or to increase the maximum dose of a previously approved medication
A request to continue psychotropic medication the child is currently taking
c.
3
This application is made during an emergency situation as defined in California Rules of Court, rule 5.640(i).
The emergency circumstances requiring the temporary administration of psychotropic medication pending the
court’s decision on this application are:
4
Prescribing physician:
Name:
License number:
a.
b.
Address:
c.
Phone numbers:
d.
Medical specialty of prescribing physician:
Child/adolescent psychiatry
General psychiatry
Family practice/GP
Pediatrics
Other (specify):
How long have you been treating the child?
years
months
days
e.
In what capacity have you been treating the child (e.g., treating psychiatrist, treating pediatrician)?
f.
5
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):
6 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):
JV-220(A),
Judicial Council of California, www.courts.ca.gov
Physician’s Statement—Attachment
Page 1 of 6
Revised January 1, 2018, Mandatory Form
Welfare and Institutions Code, §§ 369.5; 739.5
California Rules of Court, rule 5.640
Case Number:
Child’s name:
Provide to the court your assessment of the child’s overall mental health.
I don’t know.
7
Describe the child’s symptoms, including duration, and the child’s treatment plan.
8
I don’t know.
Describe the child’s response to any current psychotropic medication.
9
a.
I don’t know.
Describe the symptoms not alleviated or ameliorated by other current or past treatment efforts.
b.
I don’t know.
JV-220(A),
Page 2 of 6
Rev. January 1, 2018
Physician’s Statement—Attachment
Case Number:
Child’s name:
10
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.
11 a.
Have other pharmacological 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.
c. 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.
Medication name (generic or brand) Reason for stopping
12
Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):
JV-220(A),
Page 3 of 6
Physician’s Statement—Attachment
Rev. January 1, 2018
Case Number:
Child’s name:
13
Relevant medical history (describe, specifying significant medical conditions, all current nonpsychotropic
medications, date of last physical examination, and any recent abnormal laboratory results)
:
I don’t know.
14
a.
All essential laboratory tests were performed.
All essential laboratory tests were not performed (explain what laboratory tests were not done and why).
b.
15
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):
other (explain):
(2)
16
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.
Milieu therapy (explain):
c.
Therapeutic Behavioral Services (TBS):
d.
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.
Speech therapy:
j.
In Home Behavioral Services (IHBS):
k.
Other modality (explain):
l.
Rev. January 1, 2018
JV-220(A),
Page 4 of 6
Physician’s Statement—Attachment
Case Number:
Child’s name:
Mandatory Information Attached: Significant side effects, warnings/contraindications, drug interactions
17
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.
agreeable
other (explain):
The caregiver’s response was
c.
18
Additional information regarding medication treatment plan and follow-up:
19
List all psychotropic medications currently administered that you propose to continue and all psychotropic
medications you propose to begin administering. Mark each psychotropic medication as New (N) or Continuing (C).
Administration schedule
C
Treatment
Maximum
Medication name (generic/brand) and
• Initial and target schedule for new medication
or
duration*
total
class, and symptoms targeted by each
• Current schedule for continuing medication
6-month
N
mg/day
• Provide mg/dose and # of doses/day
medication’s anticipated benefit to child
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.
JV-220(A),
Page 5 of 6
Physician’s Statement—Attachment
Rev. January 1, 2018