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JV-220(A)

Physician’s Statement—
Attachment

Case Number:

This form must be completed and signed by the prescribing physician. Read form JV-217-INFO, Guide to Psychotropic
Medication Forms, for more information about the required forms and the application process.

1 Information about the child (name):

Current height:

Current weight:

Ethnicity:

An initial request to administer psychotropic medication to this child
A request to start a new medication or to increase the maximum dose of a previously approved medication
A request to continue psychotropic medication the child is currently taking

This application is made during an emergency situation as defined in California Rules of Court, rule 5.640(i).
The emergency circumstances requiring the temporary administration of psychotropic medication pending the
court’s decision on this application are:

Date of birth:

Gender:

Type of request:
a.
b.
c.

Prescribing physician:
a.
b.
c.

Name:
Address:
Phone numbers:

Medical specialty of prescribing physician:

Child/adolescent psychiatry
Other (specify):

General psychiatry

Family practice/GP

Pediatrics

How long have you been treating the child?

years

months

days

In what capacity have you been treating the child (e.g., treating psychiatrist, treating pediatrician)?

License number:

This request is based on a face-to-face clinical evaluation of the child by:
a.

The prescribing physician on (date):

Other (provide name, professional status, and date of evaluation):

6 Information about the child was provided to the prescribing physician by (check all that apply):
Probation officer

Social worker

Caregiver

Teacher

Parent

Child
Public health nurse
Records (specify):
Other (specify):

Tribe

Judicial Council of California, www.courts.ca.gov
Revised January 1, 2018, Mandatory Form
Welfare and Institutions Code, §§ 369.5; 739.5
California Rules of Court, rule 5.640

Physician’s Statement—Attachment

JV-220(A), Page 1 of 6

Child’s name:

Case Number:

Provide to the court your assessment of the child’s overall mental health.

I don’t know.

Describe the child’s symptoms, including duration, and the child’s treatment plan.

I don’t know.

Describe the child’s response to any current psychotropic medication.

I don’t know.

Describe the symptoms not alleviated or ameliorated by other current or past treatment efforts.

I don’t know.

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 2 of 6

Child’s name:

Case Number:

Have nonpharmacological treatment alternatives to the proposed medications been tried in the last six months?

Yes

I don’t know.
If yes, describe the treatment and the child’s response. If no, explain why not.

11 a.

Have other pharmacological treatment alternatives to the proposed medications been tried in the last six months?

Yes

I don’t know.

If yes, describe the treatment and the child’s response. If no, explain why not.

c. List the psychotropic medications that you know were taken by the child in the past and the reason or reasons

these were stopped if the reasons are known to you.
Medication name (generic or brand) Reason for stopping

Diagnoses from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 3 of 6

Child’s name:

Case Number:

Relevant medical history (describe, specifying significant medical conditions, all current nonpsychotropic
medications, date of last physical examination, and any recent abnormal laboratory results):

I don’t know.

All essential laboratory tests were performed.

All essential laboratory tests were not performed (explain what laboratory tests were not done and why).

The child was told in an age-appropriate manner about the recommended medications, the anticipated
benefits, the possible side effects, and that a request to the court for permission to begin and/or continue the
medication will be made and that he or she may oppose the request. The child’s response was
agreeable

not agreeable

Briefly describe child’s response:

The child has not been informed of this request, the recommended medications, their anticipated benefits,
and their possible adverse reactions because:
(1)

The child lacks the capacity to provide a response (explain):

(2)

other (explain):

Individual therapy:

Therapeutic services, other than medication, in which the child is enrolled in or is recommended to participate
during the next six months (check all that apply; include frequency for therapy on blank line):
a.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

Group therapy:
Milieu therapy (explain):
Therapeutic Behavioral Services (TBS):
Therapy for children on the autism spectrum:
Art therapy:
Cognitive behavioral therapy (CBT):
Wraparound services:
American Indian/Alaska Native healing and cultural traditions:
Speech therapy:
In Home Behavioral Services (IHBS):
Other modality (explain):

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 4 of 6

Child’s name:

Case Number:

Mandatory Information Attached: Significant side effects, warnings/contraindications, drug interactions
(including those with continuing psychotropic medication and all nonpsychotropic medication currently taken by
the child), and withdrawal symptoms for each recommended medication are included in the attached material.

The caregiver was informed of the mandatory information, which is attached.

The caregiver’s response was

agreeable

other (explain):

Additional information regarding medication treatment plan and follow-up:

List all psychotropic medications currently administered that you propose to continue and all psychotropic
medications you propose to begin administering. Mark each psychotropic medication as New (N) or Continuing (C).

Medication name (generic/brand) and
class, and symptoms targeted by each
medication’s anticipated benefit to child

C
or
N

Maximum
total
mg/day

Treatment
duration*
6-month
maximum

Administration schedule
• Initial and target schedule for new medication
• Current schedule for continuing medication
• Provide mg/dose and # of doses/day
• If PRN, provide conditions and parameters for use

Med:

Class:
Targets:

Med:
Class:

Targets:

Med:
Class:
Targets:

Med:

Class:

Targets:

*Authorization to administer the medication is limited to this time frame or six months from the date the order is issued, whichever occurs first.

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 5 of 6

Child’s name:

Case Number:

Other information about the prescribed medication that you want the court to know (e.g., reasons for prescribing
more than one medication in a class, prescribing outside the approved range, or prescribing medication not approved
for a child of this age):

List all psychotropic medications currently administered that will be stopped if this application is granted.

Medication name (generic or brand) Reason for stopping

Stop immediately or over period of
time? (specify, including time)

Date:

Type or print name of prescribing physician

Signature of prescribing physician

Rev. January 1, 2018

Physician’s Statement—Attachment

JV-220(A), Page 6 of 6

Physician's Statement—Attachment

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 6
Fields(s): 168
Average fields per page: 28
Reading Level: Grade 8
LIST Grouping(s): HE-03-00-00-00, ES-05-00-00-00, HE-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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topmost_subform_page_item_dother_tf was topmostSubform[0].Page1[0].item4dother_tf[0] (0.40 conf)
topmost_subform_page_item_alicnumber_tf was topmostSubform[0].Page1[0].item4alicnumber_tf[0] (0.40 conf)
topmost_subform_page_item_tf__1 was topmostSubform[0].Page1[0].item5a_tf[0] (0.40 conf)
topmost_subform_page__1 was topmostSubform[0].Page1[0].T133[0] (0.38 conf)
topmost_subform_page__2 was topmostSubform[0].Page1[0].T138[0] (0.38 conf)
topmost_subform_page_item_height_tf was topmostSubform[0].Page1[0].item1height_tf[0] (0.40 conf)
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topmost_subform_page_item_dpediatrics_cb was topmostSubform[0].Page1[0].item4dpediatrics_cb[0] (0.40 conf)
topmost_subform_page_item_child_cb was topmostSubform[0].Page1[0].item6child_cb[0] (0.40 conf)
topmost_subform_page_item_caregiver_cb was topmostSubform[0].Page1[0].item6caregiver_cb[0] (0.40 conf)
topmost_page_item_teacher_cb was topmostSubform[0].Page1[0].item6teacher_cb[0] (0.40 conf)
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topmost_subform_page_item_parent_cb was topmostSubform[0].Page1[0].item6parent_cb[0] (0.40 conf)
topmost_subform_page_item_records_cb was topmostSubform[0].Page1[0].item6records_cb[0] (0.40 conf)
topmost_subform_page_item_cb__3 was topmostSubform[0].Page1[0].item6other_cb[0] (0.40 conf)
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topmost_subform_page_item_tribe_cb was topmostSubform[0].Page1[0].item6tribe_cb[0] (0.40 conf)
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topmost_subform_page_fill_text__10 was topmostSubform[0].Page3[0].FillText150[4] (0.44 conf)
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topmost_subform_page_fill_text__24 was topmostSubform[0].Page5[0].FillText165[0] (0.44 conf)
topmost_subform_page_fill_text__25 was topmostSubform[0].Page5[0].FillText177d[0] (0.44 conf)
topmost_subform_page_fill_text__26 was topmostSubform[0].Page5[0].FillText164[0] (0.44 conf)
topmost_subform_page__5 was topmostSubform[0].Page5[0].T95[1] (0.38 conf)
topmost_subform_page__6 was topmostSubform[0].Page5[0].T94[1] (0.38 conf)
topmost_subform_page__7 was topmostSubform[0].Page5[0].T95[2] (0.38 conf)
topmost_subform_page__8 was topmostSubform[0].Page5[0].T94[2] (0.38 conf)
topmost_subform_page__9 was topmostSubform[0].Page5[0].T95[3] (0.38 conf)
topmost_subform_page__10 was topmostSubform[0].Page5[0].T94[3] (0.38 conf)
topmost_subform_page__11 was topmostSubform[0].Page5[0].T95[4] (0.38 conf)
topmost_subform_page__12 was topmostSubform[0].Page5[0].T95[5] (0.38 conf)
topmost_subform_page__13 was topmostSubform[0].Page5[0].T95[6] (0.38 conf)
topmost_subform_page__14 was topmostSubform[0].Page5[0].T95[7] (0.38 conf)
topmost_subform_page_item_cb__16 was topmostSubform[0].Page5[0].item18a_cb[1] (0.40 conf)
topmost_page_childsname_ft__6 was topmostSubform[0].Page6[0].childsname_ft[0] (0.40 conf)
topmost_page_case_number_ft__6 was topmostSubform[0].Page6[0].CaseNumber_ft[0] (0.43 conf)
topmost_subform_page__15 was topmostSubform[0].Page6[0].T6[0] (0.38 conf)
topmost_subform_page_fill_text__27 was topmostSubform[0].Page6[0].FillText155[0] (0.44 conf)
topmost_subform_page_fill_text__28 was topmostSubform[0].Page6[0].FillText152[0] (0.44 conf)
topmost_subform_page_printname was topmostSubform[0].Page6[0].printname[0] (0.40 conf)
topmost_subform_page_item_tf__13 was topmostSubform[0].Page6[0].item20_tf[0] (0.40 conf)
topmost_subform_page_fill_text__29 was topmostSubform[0].Page6[0].FillText155[1] (0.44 conf)
topmost_subform_page_fill_text__30 was topmostSubform[0].Page6[0].FillText155[2] (0.44 conf)
topmost_subform_page_fill_text__31 was topmostSubform[0].Page6[0].FillText152[1] (0.44 conf)
topmost_subform_page_fill_text__32 was topmostSubform[0].Page6[0].FillText155[3] (0.44 conf)
topmost_subform_page_fill_text__33 was topmostSubform[0].Page6[0].FillText155[4] (0.44 conf)
topmost_subform_page_fill_text__34 was topmostSubform[0].Page6[0].FillText152[2] (0.44 conf)
topmost_subform_page_fill_text__35 was topmostSubform[0].Page6[0].FillText155[5] (0.44 conf)
topmost_subform_page_fill_text__36 was topmostSubform[0].Page6[0].FillText155[6] (0.44 conf)
topmost_subform_page_fill_text__37 was topmostSubform[0].Page6[0].FillText152[3] (0.44 conf)
topmost_subform_page_fill_text__38 was topmostSubform[0].Page6[0].FillText155[7] (0.44 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

topmost_subform_page_item_aname_tf
topmost_page_item_baddress
topmost_page_item_cphone
topmost_subform_page_item_dother_tf
topmost_subform_page_item_alicnumber_tf
topmost_subform_page_item_tf__1
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topmost_subform_page_item_cb__1
topmost_subform_page_item_b_cb__1
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topmost_subform_page_item_records_cb
topmost_subform_page_item_cb__3
topmost_subform_page_item_bother_tf
topmost_subform_page_item_cb__4
topmost_subform_page_item_b_cb__2
topmost_subform_page_item_c_cb__1
topmost_subform_page_item_nurse_cb
topmost_subform_page_item_eyears_tf
topmost_subform_page_item_emonths_tf
topmost_subform_page_item_edays_tf
topmost_subform_page_item_tribe_cb
topmost_subform_page_item_f_tf__1
topmost_page_childsname_ft__2
topmost_page_case_number_ft__2
topmost_subform_page_item_tf__3
topmost_subform_page_item_idk_cb__1
topmost_subform_page_item_idk_cb__2
topmost_subform_page_item_idk_cb__3
topmost_subform_page_item_tf__4
topmost_subform_page_item_tf__5
topmost_subform_page_item_idk_cb__4
topmost_subform_page_item_b_tf__1
topmost_page_childsname_ft__3
topmost_page_case_number_ft__3
topmost_subform_page_fill_text__1
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topmost_subform_page_item_cb__5
topmost_subform_page_item_cb__6
topmost_subform_page_item_b_tf__2
topmost_subform_page_item_cb__7
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topmost_subform_page_item_b_tf__3
topmost_subform_page_item_tf__6
topmost_subform_page_item_cb__9
topmost_subform_page_item_cb__10
topmost_page_childsname_ft__4
topmost_page_case_number_ft__4
topmost_subform_page_item_b_tf__4
topmost_subform_page_item_b_cb__3
topmost_subform_page_item_b_tf__5
topmost_subform_page_item_b_cb__4
topmost_subform_page_item_b_cb__5
topmost_subform_page_item_tf__7
topmost_subform_page_item_cb__11
topmost_subform_page_item_aagreeable_cb__1
topmost_subform_page_item_anotagreeable_cb
topmost_subform_page_item_ab_cb__1
topmost_subform_page_item_ab_cb__2
topmost_subform_page_item_b_tf__6
topmost_subform_page_item_idk_cb__5
topmost_subform_page_item_tf__8
topmost_subform_page_item_tf__9
topmost_subform_page_item_b_tf__7
topmost_subform_page_item_c_tf__1
topmost_subform_page_item_cb__12
topmost_subform_page_item_c_cb__2
topmost_subform_page_item_b_cb__6
topmost_subform_page_item_tf__10
topmost_subform_page_item_cb__13
topmost_subform_page_item_f_tf__2
topmost_subform_page_item_f_cb
topmost_subform_page_item_g_tf
topmost_subform_page_item_g_cb
topmost_subform_page_item_j_tf
topmost_subform_page_item_j_cb
topmost_subform_page_item_k_tf
topmost_subform_page_item_k_cb
topmost_subform_page_item_e_tf
topmost_subform_page_item_e_cb
topmost_subform_page_item_h_tf
topmost_subform_page_item_h_cb
topmost_subform_page_item_tf__11
topmost_subform_page_item_cb__14
topmost_subform_page_item_l_tf
topmost_subform_page_item_l_cb
topmost_page_childsname_ft__5
topmost_page_case_number_ft__5
topmost_subform_page_item_cb__15
topmost_subform_page_item_aagreeable_cb__2
topmost_subform_page_item_aother_cb
topmost_subform_page_item_c_tf__2
topmost_subform_page_item_tf__12
topmost_subform_page__3
topmost_subform_page__4
topmost_subform_page_fill_text__13
topmost_subform_page_fill_text__14
topmost_subform_page_fill_text__15
topmost_subform_page_fill_text__16
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topmost_subform_page_fill_text__18
topmost_subform_page_fill_text_n
topmost_subform_page_fill_text__19
topmost_subform_page_fill_text__20
topmost_subform_page_fill_text__21
topmost_page_fill_text_c
topmost_subform_page_fill_text__22
topmost_subform_page_fill_text__23
topmost_subform_page_fill_text__24
topmost_subform_page_fill_text__25
topmost_subform_page_fill_text__26
topmost_subform_page__5
topmost_subform_page__6
topmost_subform_page__7
topmost_subform_page__8
topmost_subform_page__9
topmost_subform_page__10
topmost_subform_page__11
topmost_subform_page__12
topmost_subform_page__13
topmost_subform_page__14
topmost_subform_page_item_cb__16
topmost_page_childsname_ft__6
topmost_page_case_number_ft__6
topmost_subform_page__15
topmost_subform_page_fill_text__27
topmost_subform_page_fill_text__28
topmost_subform_page_printname
topmost_subform_page_item_tf__13
topmost_subform_page_fill_text__29
topmost_subform_page_fill_text__30
topmost_subform_page_fill_text__31
topmost_subform_page_fill_text__32
topmost_subform_page_fill_text__33
topmost_subform_page_fill_text__34
topmost_subform_page_fill_text__35
topmost_subform_page_fill_text__36
topmost_subform_page_fill_text__37
topmost_subform_page_fill_text__38

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