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Proof Of Notice Application Regarding Psychotropic Medication JV-221 - California

Proof Of Notice Application Regarding Psychotropic Medication Form. This is a California form and can be used in Juvenile Judicial Council .
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JV-221 Proof of Notice: Application Regarding Psychotropic Medication Clerk stamps date here when form is filed. Read JV-219-INFO, Information About Psychotropic Medication Forms, for more information about the required forms and the application process. 1 The following parents/legal guardians of the child were notified 1 of the physician's request to begin and/or to continue administering psychotropic medication, of the name of each medication, and that a JV-220, Application Regarding Psychotropic Medication, and a JV-220(A), Prescribing Physician's Statement--Attachment, are pending before the court. They were also provided with JV-219-INFO, Information About Psychotropic Medication Forms, and a blank copy Fill in court name and street address: of JV-222, Opposition to Application Regarding Psychotropic Superior Court of California, County of Medication, or with information on how to obtain a copy of each form. a. Name: Date notified: Relationship to child: Manner: In person By phone at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219Fill in child's name and date of birth: INFO and JV-222 in a sealed envelope in the United States mail, Child's Name with first-class postage prepaid, to the last known address Date of Birth: (specify): b. Name: Court fills in case number when form is filed. Date notified: Case Number: Relationship to child: Manner: In person By phone at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): c. Name: Date notified: Relationship to child: Manner: In person By phone at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): 2 3 Parental rights were terminated, and the child has no legal parents who must be informed. Parent/legal guardian (name): was not informed because (state reason): Parent/legal guardian (name): 4 was not informed because (state reason): 5 The child's current caregiver was notified that a physician is asking to treat the child with psychotropic medication and that a JV-220 and a JV-220(A) are pending before the court as follows: Caregiver (name): Manner: By electronic service at (e-mail address): In person By phone at (specify): By depositing the required information (time sent): in a sealed envelope in the United States mail, with first-class postage prepaid, to the following address (specify): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Type or print name Judicial Council of California, www.courts.ca.gov Revised January 1, 2014, Mandatory Form Welfare and Institutions Code, ยง 369.5 California Rules of Court, rule 5.640 Sign your name Signature follows on page 3. JV-221, Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Proof of Notice: Application Regarding Psychotropic Medication Case Number: Child's Name: 6 The child's attorney and the child's CAPTA guardian ad litem, if that person is someone other than the child's attorney, were provided with completed JV-220, Application Regarding Psychotropic Medication, and JV-220 (A), Prescribing Physician's Statement--Attachment; a copy of JV-219-INFO, Information About Psychotropic Medication Forms; and a blank copy of JV-222, Opposition to Application Regarding Psychotropic Medication, as follows: a. Attorney's name: Date notified: (specify): Manner: In person By fax at By electronic service at (e-mail address): (time sent): By depositing copies in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): b. CAPTA guardian ad litem's name: Date notified: Manner: In person By fax at (specify): By electronic service at (e-mail address): (time sent): By depositing copies in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): The following attorneys were notified of the physician's request to begin and/or continue administering psychotropic medication, of the name of each medication, and that a JV-220, Application Regarding Psychotropic Medication. and a JV-220(A), Prescribing Physician's Statement--Attachment, are pending before the court. They were also provided with a copy of JV-219-INFO, Information About Psychotropic Medication Forms, and a blank copy of JV-222, Opposition to Application Regarding Psychotropic Medication, or with information on how to obtain a copy of each form as follows: a. Attorney's name: Date notified: Attorney for (name): Manner: In person By phone at (specify): By fax at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): b. Attorney's name: Date notified: Attorney for (name): Manner: In person By phone at (specify): By fax at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): c. Attorney's name: Date notified: Attorney for (name): Manner: In person By phone at (specify): By fax at (specify): By electronic service at (e-mail address): (time sent): By depositing the required information and copies of JV-219-INFO and JV-222 in a sealed envelope in the United States mail, with first-class postage prepaid, to the last known address (specify): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Type or print name Rev. January 1, 2014 7 Sign your name Signature follows on page 3. JV-221, Page 2 of 3 Proof of Notice: Application Regarding Psychotropic Medication Case Number: Child's Name: 8 The child's CASA volunteer was notified that a JV-220 and a JV-220(A) are pending before the court as follows: Date notified: CASA volunteer (name): Manner: In person By phone at (specify): By electronic ser
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