b.

c.

d.

e.

f.

g.
h.

1

2

3

JV-223

Order on Application for 
Psychotropic Medication

The Court read and considered:
a. Form JV-220, Application for Psychotropic Medication, and form  
JV-220(A),  Physician’s Statement—Attachment, or JV-220(B), 
Physician’s Request to Continue Medication—Attachment filed on (date): 

Clerk stamps date here when form is filed.

Form JV-218, Child’s Opinion About the Medicine,   
filed on (date):

Form JV-219, Statement About Medicine Prescribed,
filed on (date):

Form JV-219, Statement About Medicine Prescribed,
filed on (date):

Form JV-222, Input on Application for Psychotropic Medication,   
filed on (date):
Form JV-222, Input on Application for Psychotropic Medication,   
filed on (date):
CASA report
Other (specify):

The Court finds and orders:

a. 
b.

Notice requirements were met.
Notice requirements were not met. Proper notice was not given to:

Fill in court name and street address:

Superior Court of California, County of

Fill in child's name and date of birth:

Child's Name:

Date of Birth:

Case Number:

Court fills in case number when form is filed.

The matter is set for hearing on (date): 

at (time):

in (dept.):

Application was made for authorization to begin or to continue giving the child the psychotropic medication 
listed in       on page 5 of form JV-220(A) or       on page 4 of form JV-220(B).  

19

16

Copies of pages 5 and 6 of form JV-220(A) or pages 3 and 4 of form JV-220(B) are attached to this order. 
The application is (check one):
a.
b.

Granted as requested. 
Granted with the following modifications or conditions to the request as made in       on page 5 of form
JV-220(A) or       on page 4 of form JV-220(B) (specify all modifications and conditions):

16

19

c.

Denied (specify reason for denial):

If the application was for medication the child is currently taking, the social worker or probation officer 
must consult with the prescribing physician to determine whether the physician is recommending that the 
medication should be stopped immediately or gradually reduced over time. 

Judicial Council of California,  www.courts.ca.gov  
Rev. September 1, 2020, Mandatory Form  
Welfare and Institutions Code, §§ 369.5, 739.5, 14028  
California Rules of Court, rules 5.640 and 5.642

Order on Application for  
Psychotropic Medication

JV-223, Page 1 of 2

Case Number:

Child’s name:

4

a.

b.

This authorization will not result in the child being prescribed three or more psychotropic medications at the 
same time for 90 days or more. 

This authorization will result in the  child being prescribed three or more psychotropic medications at the 
same time for 90 days or more, which meets the description in Welfare and Institutions Code section 14028 
of the data the California Department of Health Care Services and the California Department of Social 
Services must share with the Medical Board of California in order to ascertain whether there is excessive 
prescribing of psychotropic medication. The applicant must provide the child and the child's attorney a blank 
copy of Position on Release of Information to Medical Board of California (form JV-228) and a copy of 
Background on Release of Information to Medical Board of California (form JV-228-INFO), and a blank 
copy of Withdrawal of Release of Information to Medical Board of California (form JV-229). The 
procedures in California Rules of Court, rule 5.642 must be followed.

5

The applicant must resubmit the application no later than (date): 
with the missing information, which is:

The matter is set for hearing on (date): 
in (dept.):

at (time):

6

The

social worker
probation officer
person who submitted application

a.
b.
c.
is ordered to give a copy of this order, including pages 5 and 6 of form JV-220(A) or pages 3 and 4 of form  
JV-220(B) and the medication monograph attached to the form JV-220(A) to the child’s caregiver either in person 
or by mail within two court days.

Other (specify):

7

8

The order is set for a progress review on (date):  
in (dept.):

at (time):

This order is effective until terminated or modified by court order or until 180 days from the date of this  
order, whichever is earlier. If the prescribing physician is no longer treating the child, this order extends to 
subsequent treating physicians. A change in the child’s placement does not require a new order regarding  
psychotropic medication. Except in an emergency situation, a new application must be submitted and  
consent granted by the court before giving the child medication not authorized in this order or increasing  
medication dosage beyond the maximum daily dosage authorized in this order. 

Date:

Rev. September 1, 2020

Signature of judge or judicial officer

Order on Application for  
Psychotropic Medication

JV-223, Page 2 of 2