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Here is the text we could read:

Clerk stamps date here when form is filed.

JV-220

Application for
Psychotropic Medication
A completed and signed Physician’s Statement—Attachment
(form JV-220(A)), or Physician’s Request to Continue Medication—
Attachment (form JV-220(B)) with all its attachments must be attached to this
form before it is filed with the court. Read form JV-217-INFO, Guide to
Psychotropic Medication Forms, for more information about the required
forms and the application process.

Information about where the child lives:

a. The child lives

with a relative

in a foster home

with a nonrelative extended family member
in a group home, level
in a short-term residential therapeutic program
other (specify):

at a juvenile custodial facility

Superior Court of California, County of

Fill in court name and street address:

b. If applicable, the name of the facility where the child lives:

c. Contact information for a responsible adult where the child lives:

(1)
(2)

Name:
Phone:

Fill in child's name and date of birth:

Child's Name:

Date of Birth:

Case Number:

d. The child has lived at the placement in (a) since (insert date):

Court fills in case number when form is filed.

Information about the child’s current location:
a.
b.

The child remains at the location identified in .
1
The child is currently staying in:

(1)
(2)
(3)

a psychiatric hospital (name):
a juvenile hall (name):
other (specify):

social worker

probation officer

Child’s
a. Name:
b.
c.

Address:
Phone:

Date:

Number of pages attached:

Type or print name of person completing this form

Signature

E-mail:

Fax:

Child welfare services staff (sign above, complete items
– , and sign on page 4)
1
Probation department staff (sign above, complete items
– , and sign on page 4)
1
Medical office staff (sign above)
Caregiver (sign above)
Prescribing physician (sign on page 6 of JV-220(A)
or page 4 of JV-220(B))

JV-220, Page 1 of 4

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

Application for
Psychotropic Medication

Child’s name:

Case Number:

If you are the child's social worker or probation officer, you must fill out items 5–13 of this form. If you do not know the
answer to a question, write “I do not know.” If you are not the child’s social worker or probation officer, you do not need
to fill out items 5–13 of this form.

Describe if the child has shared feelings about starting to take medication. If this is a request to renew or modify
medication, include what the child reports regarding the benefits and side effects of having taken the medication.

The child will provide input on the medication being prescribed (check all that apply):

a.
c.
e.
g.

Through the social worker/probation officer.
Through his or her CASA.
By writing a letter to the judge.
Other (specify):

b.
d.
f.

Through his or her attorney.
By filling out form JV-218.
By talking to the judge at a hearing.

Describe what the caregiver reports regarding the child being placed on the medication. If this is a request to renew
or modify medication, include what the caregiver reports regarding the benefits and side effects of having the child
take medication.

The caregiver will provide input on the medication being prescribed (check all that apply):

Through the social worker/probation officer.
By filling out form JV-219.
By writing a letter to the judge.
By talking to the judge at a hearing.
Other (specify):

a.
b.
c.
d.
e.

Is the information provided by the physician on form JV-220(A) at questions 10 and 11 or on form JV-220(B) at
question 8 accurate, to the best of your knowledge?

Yes

I do not know

Do you have additional information about mental health treatment alternatives to the proposed medications that
have been used in the last six months? If yes, explain:

Yes

Rev. January 1, 2018

Application for
Psychotropic Medication

JV-220, Page 2 of 4

Child’s name:

Case Number:

c. Do you have additional information to add about other psychotropic medications that have been tried in the last

six months? If yes, explain:

Yes

d. 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

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

Group therapy:
Milieu therapy (explain):

Individual therapy:

Therapeutic Behavioral Services (TBS):

Therapy for children on the autism spectrum:

j.
k.

Art therapy:
Cognitive behavioral therapy (CBT):

f.
g.
h. Wraparound services:
i.

Speech therapy:
In Home Behavioral Services (IHBS):

Other modality (explain):

American Indian/Alaska Native healing and cultural traditions:

What other services could benefit or enhance the child’s well-being (for example, sports, art, extracurricular
activities)?

Rev. January 1, 2018

JV-220, Page 3 of 4

Application for
Psychotropic Medication

Child’s name:

Case Number:

What comments, if any, do you have regarding the application? What else do you want the judge to know?

Check here if you need more space for any of the items. Write the item number and additional information here.
If you need more space, attach a sheet or sheets of paper.

Type or print name of person completing this form

Date:

Rev. January 1, 2018

}
Signature

Child welfare services staff (sign above)
Probation department staff (sign above)

Application for
Psychotropic Medication

JV-220, Page 4 of 4

Application For Psychotropic Medication

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): 4
Fields(s): 115
Average fields per page: 28
Reading Level: Grade 7
LIST Grouping(s): 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__5 was topmostSubform[0].Page1[0].T177[0] (0.38 conf)
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topmost_subform_page_signaturemedical_cb was topmostSubform[0].Page1[0].signaturemedical_cb[0] (0.40 conf)
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We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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topmost_subform_page_item_b_cb__2
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Application For Psychotropic Medication

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