Form JV-219 "Statement About Medicine Prescribed" - California

What Is Form JV-219?

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-219 by clicking the link below or browse more documents and templates provided by the California Superior Court.

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Download Form JV-219 "Statement About Medicine Prescribed" - California

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Statement About Medicine
Clerk stamps date here when form is filed.
JV-219
Prescribed
You may use this form to give the court input on the request for an order for
medication for the youth.
You do not have to use this form if you do not want to. There are other ways to
give input to the court. You may:
• Send a letter to the judge,
• Speak to the judge at the hearing, or
Fill in court name and street address:
• Ask your lawyer or the child’s social worker, probation officer, or CASA
Superior Court of California, County of
to tell the judge how you feel.
You may add pages to this form if you need more space for your answers.
Please put the child’s name and the number of the question you are answering
on each extra page.
Child’s name:
Fill in child's name and date of birth:
(last)
(first)
(middle)
Child's Name:
Your name:
1
(last)
Date of Birth:
(first)
(middle)
Court fills in case number when form is filed.
2
Your relationship to the child:
Caregiver
CASA
Parent
Case Number:
Legal Guardian
Indian Tribe
Other (explain):
3
How long have you known the child?
(years)
(months)
(days)
4
How long has the child lived in your home or facility?
(days)
(years)
(months)
The child does not live with me.
Child’s Behavior
5
How does the child act at home?
Don’t know
Describe here:
6
How does the child act at school?
Don’t know
Describe here:
Judicial Council of California, www.courts.ca.gov
Statement About Medicine Prescribed
JV-219,
Page 1 of 4
Revised January 1, 2018, Optional Form
Welfare and Institutions Code, §§ 369.5, 739.5
California Rules of Court, rule 5.640
Statement About Medicine
Clerk stamps date here when form is filed.
JV-219
Prescribed
You may use this form to give the court input on the request for an order for
medication for the youth.
You do not have to use this form if you do not want to. There are other ways to
give input to the court. You may:
• Send a letter to the judge,
• Speak to the judge at the hearing, or
Fill in court name and street address:
• Ask your lawyer or the child’s social worker, probation officer, or CASA
Superior Court of California, County of
to tell the judge how you feel.
You may add pages to this form if you need more space for your answers.
Please put the child’s name and the number of the question you are answering
on each extra page.
Child’s name:
Fill in child's name and date of birth:
(last)
(first)
(middle)
Child's Name:
Your name:
1
(last)
Date of Birth:
(first)
(middle)
Court fills in case number when form is filed.
2
Your relationship to the child:
Caregiver
CASA
Parent
Case Number:
Legal Guardian
Indian Tribe
Other (explain):
3
How long have you known the child?
(years)
(months)
(days)
4
How long has the child lived in your home or facility?
(days)
(years)
(months)
The child does not live with me.
Child’s Behavior
5
How does the child act at home?
Don’t know
Describe here:
6
How does the child act at school?
Don’t know
Describe here:
Judicial Council of California, www.courts.ca.gov
Statement About Medicine Prescribed
JV-219,
Page 1 of 4
Revised January 1, 2018, Optional Form
Welfare and Institutions Code, §§ 369.5, 739.5
California Rules of Court, rule 5.640
Case Number:
Child’s name:
7
How does the child interact with friends and peers?
Don’t know
Describe here:
8
How does the child interact with adults?
Don’t know
Describe here:
9
How does the child sleep?
Don’t know
Describe how well the child sleeps and about how many hours each day:
Describe the Child’s Treatment Now
List any other treatment the child is doing now:
10
None
Individual talk therapy
Family therapy
Group talk therapy
Counseling at school
Art or play therapy
Cognitive Behavioral Therapy (CBT or practicing behaviors)
Other (list any other treatment here):
11 List all the medicines the child takes regularly now:
Don’t know
Name of medicine:
Dose (if you know):
Name of medicine:
Dose (if you know):
Name of medicine:
Dose (if you know):
Other medicines (list here):
12 Did you meet with the doctor who prescribed the psychotropic medicine?
Yes
No
If Yes:
a. Did the doctor explain the medicine’s expected benefits, and possible side
Yes
No
effects, and provide other information about the medicine?
b. Did you give the doctor information about the child?
Yes
No
c. Do you agree with use of the medication?
Yes
No
Not sure
Statement About Medicine Prescribed
Rev. January 1, 2018
JV-219,
Page 2 of 4
Case Number:
Child’s name:
13
Follow-up and Maintenance
a.
Do you know about the child’s follow-up plan with this doctor?
Yes
No
b.
Do you know how to schedule follow-up appointments with this doctor?
Yes
No
c.
Do you know how and where to get the medicine the doctor prescribed?
Yes
No
d. Do you know how to make sure the child gets to the follow-up appointments?
Yes
No
e. Do you know how the child is supposed to take this medicine?
Yes
No
f. Do you know who is in charge of making sure s/he takes the medicine correctly?
Yes
No
If Yes, describe here:
g. Do you know what to do if the child has a bad reaction to the medicine?
Yes
No
List below anything else you want the judge to know.
14
Fill out questions 15
23 ONLY if the child is taking psychotropic medicine now
If the child is not taking this/any psychotropic medicine now, skip to question 24.
Does the medicine affect the child’s school or ability to learn?
15
Yes
No
Don’t know
If Yes, describe here:
16
Does the medicine affect the child’s ability to concentrate?
Yes
No
Don’t know
If Yes, describe here:
Does the child have reasonable energy levels throughout the day?
17
Yes
No
Don’t know
If No, describe here:
18 Does the medicine affect the child’s participation in hobbies or after-school activities?
Yes
No
Don’t know
If Yes, describe here:
Statement About Medicine Prescribed
Rev. January 1, 2018
JV-219,
Page 3 of 4
Case Number:
Child's name:
19 Is it easy to get the child to take the medicine?
Yes
No
Don’t know
If No, describe what it’s like:
20 Does anyone talk to the child about how he or she feels when he or she is on this medicine?
Yes
No
Don’t know
If Yes, explain who and how often:
21
Has the child’s weight changed with this medicine?
Yes
No
Don’t know
If Yes, check one:
Lost weight
Gained weight
How many pounds?
22 List any other side effects from the medicine:
Headache
Constipation
Confusion
Feel dizzy
Problems sleeping
Feeling very sleepy
Nausea
Other (list any other side effects here):
23
List any benefits you have noticed from the child’s taking this medicine:
24
Check here if you are going to add extra pages to this form. And say how many pages:
Date:
Sign your name
Type or print your name
Statement About Medicine Prescribed
Rev. January 1, 2018
JV-219,
Page 4 of 4
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