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l al f4yt'4 E X T ) F O R M T E X T F O R M T E X T S e c t i o n C C o n s e n t f o r a d m i n i s t r a t i o n o f p s y c h o t r o p i c m e d i c a t i o n s ( s i g n e d b y l e g a l p a r e n t o r l e g a l g u a r d i a n ) : I h a v e b e e n i n f o r m e d o f t h e r e c o m m e n d a t i o n t o p r e s c r i b e m e d i c a t i o n s a s p a r t o f m y t r e a t m e n t . I h a v e b e e n i n f o r m e d o f t h e n a t u r e o f m y c o n d i t i o n , t h e r i s k s a n d b e n e f i t s o r t r e a t m e n t w i t h t h e m e d i c a t i o n s , o f o t h e r f o r m s o f t r e a t m e n t , a s w e l l a s t h e r i s k s o f n o t r e a t m e n t . F o s t e r P a r e n t s c a n n o t c o n s e n t t o a d m i n i s t r a t i o n o f p s y c h o t r o p i c m e d i c a t i o n s F O R M C H E C K B O X B y s i g n i n g b e l o w , I g i v e c o n s e n t f o r t o r e c e i v e t h e m e d i c a t i o n s l i s t e d i n s e c t i o n A , a s r e c o m m e n d e d b y h i s / h e r l i c e n s e d h e a l t h c a r e p r o v i d e r . I u n d e r s t a n d t h a t I c a n w i t h d r a w t h i s c o n s e n t f o r m y c h i l d t o r e c e i v e m e d i c a t i o n s a t a n y t i m e d u r i n g h i s / h e r t r e a t m e n t . F O R M C H E C K B O X B y s i g n i n g b e l o w , I d o n o t g i v e c o n s e n t f o r t o r e c e i v e t h e m e d i c a t i o n s l i s t e d i n s e c t i o n A , a s r e c o m m e n d e d b y h i s / h e r l i c e n s e d h e a l t h c a r e p r o v i d e r . R e a s o n c o n s e n t d e n i e d : 2 A u t h o r i z e d S i g n a t u r e D a t e R e l a t i o n s h i p t o C h i l d : P r i n t N a m e : S e c t i o n C C o n s e n t f o r a d m i n i s t r a t i o n o f p s y c h o t r o p i c m e d i c a t i o n s ( s i g n e d b y y o u t h a g e 1 8 o r o l d e r ) : I h a v e b e e n i n f o r m e d o f t h e r e c o m m e n d a t i o n t o p r e s c r i b e m e d i c a t i o n s a s p a r t o f m y t r e a t m e n t . I h a v e b e e n i n f o r m e d o f t h e n a t u r e o f m y c o n d i t i o n , t h e r i s k s a n d b e n e f i t s o r t r e a t m e n t w i t h t h e m e d i c a t i o n s , o f o t h e r f o r m s o f t r e a t m e n t , a s w e l l a s t h e r i s k s o f n o t r e a t m e n t . S i g n a t u r e D a t e A n e w s i g n e d c o n s e n t i s r e q u i r e d o n c e a y e a r , w h e n a n e w m e d i c a t i o n i s s t a r t e d a n d / o r w h e n t h e d o s a g e e x c e e d s t h e m a x i m u m i n d i c a t e d i n t h e d o s a g e r a n g e . C r i t e r i a T r i g g e r i n g F u r t h e r R e v i e w F O R M C H E C K B O X P r e s c r i b e d f o u r o r m o r e c o n c o m i t a n t p s y c h o t r o p i c m e d i c a t i o n s F O R M C H E C K B O X P r e s c r i b e d t w o o r m o r e c o n c o m i t a n t a n t i - d e p r e s s a n t s . F O R M C H E C K B O X P r e s c r i b e d t w o o r m o r e c o n c o m i t a n t a n t i - p s y c h o t i c s . F O R M C H E C K B O X P r e s c r i b e d t w o o r m o r e c o n c o m i t a n t s t i m u l a n t m e d i c a t i o n s . F O R M C H E C K B O X P r e s c r i b e d t w o o r m o r e c o n c o m i t a n t m o o d s t a b i l i z e r m e d i c a t i o n s . F O R M C H E C K B O X P r e s c r i b e d p s y c h o t r o p i c m e d i c a t i o n s i n d o s e s a b o v e r e c o m m e n d e d d o s e s F O R M C H E C K B O X P r e s c r i b e d p s y c h o t r o p i c m e d i c a t i o n a n d c h i l d i s f i v e y e a r s o r y o u n g e r . 1 T o t h e p h y s i c i a n : I n c o m p l i a n c e w i t h t h e M D H S G u i d e l i n e s f o r t h e U s e o f P s y c h o t r o p i c M e d i c a t i o n f o r C h i l d r e n i n S t a t e C u s t o d y , t h e a b o v e m e d i c a t i o n c o m b i n a t i o n s s h o u l d b e a v o i d e d . T h e s e p a r a m e t e r s d o n o t n e c e s s a r i l y i n d i c a t e t r e a t m e n t i s i n a p p r o p r i a t e , b u t f o r D H S p u r p o s e s f u r t h e r r e v i e w i s n e e d e d . C h e c k t h e a p p r o p r i a t e b o x i f a n y a p p l y . A n e x p l a n a t i o n m u s t b e p r o v i d e d w i t h i n t h e r a t i o n a l e s e c t i o n ( u n d e r t h e M e d i c a t i o n s o n p g . 1 ) , a n d y o u m a y b e c o n t a c t e d f o r f o l l o w u p .
1 T o t h e c a s e w o r k e r : I f t h e R a t i o n a l e f i e l d i n s e c t i o n A i s c o m p l e t e d a n d o n e o r m o r e o f t h e c h e c k b o x e s a r e c h e c k e d , a c o p y o f t h e c o m p l e t e d P s y c h o t r o p i c M e d i c a t i o n C o n s e n t F o r m m u s t b e f a x e d t o t h e D H S H e a l t h , E d u c a t i o n & Y o u t h U n i t a t 5 1 7 - 3 3 5 - 7 7 8 9 .
2 I f c o n s e n t i s d e n i e d a n d a l l o t h e r p a r t i e s a g r e e m e d i c a t i o n i s n e e d e d , a c o u r t o r d e r i s n e c e s s a r y f o r m e d i c a t i o n t o b e a d m i n i s t e r e d .
D e p a r t m e n t o f H u m a n S e r v i c e s ( D H S ) w i l l n o t d i s c r i m i n a t e a g a i n s t a n y i n d i v i d u a l o r g r o u p b e c a u s e o f r a c e , r e l i g i o n , a g e , n a t i o n a l o r i g i n , c o l o r , h e i g h t , w e i g h t , m a r i t a l s t a t u s , s e x , s e x u a l o r i e n t a t i o n , g e n d e r i d e n t i t y o r e x p r e s s i o n , p o l i t i c a l b e l i e f s o r d i s a b i l i t y . I f y o u n e e d h e l p w i t h r e a d i n g , w r i t i n g , h e a r i n g , e t c . , u n d e r t h e A m e r i c a n s w i t h D i s a b i l i t i e s A c t , y o u a r e i n v i t e d t o m a k e y o u r n e e d s k n o w n t o a D H S o f f i c e i n y o u r a r e a .
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