Physicians Statement-Attachment {JV-220(A)} | Pdf Fpdf Docx | California

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Physicians Statement-Attachment {JV-220(A)} | Pdf Fpdf Docx | California

Physicians Statement-Attachment {JV-220(A)}

This is a California form that can be used for Juvenile within Judicial Council.

Alternate TextLast updated: 1/5/2018

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www.courts.ca.gov (specify): Guide to PsychotropicMedication Forms, (date): (check all that apply): (specify): (specify): (name): (provide name, professional status, and date of evaluation): American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Medication name (generic or brand)Reason for stopping Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5): American LegalNet, Inc. www.FormsWorkFlow.com (explain): (explain): (explain what laboratory tests were not done and why). (describe, specifying significant medical conditions, all current nonpsychotropic medications, date of last physical examination, and any recent abnormal laboratory results): (explain):(check all that apply; include frequency for therapy on blank line): (explain):l. American LegalNet, Inc. www.FormsWorkFlow.com (explain): Medication name (generic/brand) and class, and symptoms targeted by each medication222s anticipated benefit to child C or NMaximum total mg/dayTreatment duration* 6-month maximumAdministration schedule *Authorization to administer the medication is limited to this time frame or six months from the date the order is issued, whichever occurs first. American LegalNet, Inc. www.FormsWorkFlow.com Signature of prescribing physician Medication name (generic or brand) Reason for stopping Type or print name of prescribing physician Stop immediately or over period of time? (specify, including time) American LegalNet, Inc. www.FormsWorkFlow.com

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