The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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Here is the text we could read:

JV-219

Statement About Medicine
Prescribed

Clerk stamps date here when form is filed.

You may use this form to give the court input on the request for an order for
medication for the youth.

You do not have to use this form if you do not want to. There are other ways to
give input to the court. You may:

• Send a letter to the judge,
• Speak to the judge at the hearing, or
• Ask your lawyer or the child’s social worker, probation officer, or CASA

to tell the judge how you feel.

You may add pages to this form if you need more space for your answers.
Please put the child’s name and the number of the question you are answering
on each extra page.

Fill in court name and street address:

Superior Court of California, County of

Child’s name:

1 Your name:

(first)

(middle)

(last)

Fill in child's name and date of birth:

(first)

(middle)

(last)

Your relationship to the child:

Court fills in case number when form is filed.

Child's Name:

Date of Birth:

Case Number:

Caregiver
Legal Guardian
Other (explain):

CASA

Parent

Indian Tribe

(years)

(months)

(days)

How long have you known the child?

How long has the child lived in your home or facility?

The child does not live with me.

Child’s Behavior

How does the child act at home?
Describe here:

Don’t know

(years)

(months)

(days)

How does the child act at school?

Don’t know

Describe here:

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

Statement About Medicine Prescribed

JV-219, Page 1 of 4

Child’s name:

Describe here:

How does the child interact with friends and peers?

Don’t know

Case Number:

How does the child interact with adults?

Don’t know

Describe here:

How does the child sleep?

Don’t know

Describe how well the child sleeps and about how many hours each day:

Describe the Child’s Treatment Now

List any other treatment the child is doing now:

None
Group talk therapy
Cognitive Behavioral Therapy (CBT or practicing behaviors)
Other (list any other treatment here):

Individual talk therapy
Counseling at school

11 List all the medicines the child takes regularly now:

Don’t know

Family therapy
Art or play therapy

Dose (if you know):
Dose (if you know):
Dose (if you know):

Name of medicine:
Name of medicine:
Name of medicine:

Other medicines (list here):

If Yes:

12 Did you meet with the doctor who prescribed the psychotropic medicine?

Yes

a. Did the doctor explain the medicine’s expected benefits, and possible side

effects, and provide other information about the medicine?

b. Did you give the doctor information about the child?

c. Do you agree with use of the medication?

Yes

Not sure

Rev. January 1, 2018

Statement About Medicine Prescribed

JV-219, Page 2 of 4

Child’s name:

Case Number:

Follow-up and Maintenance
a.

Do you know about the child’s follow-up plan with this doctor?

Do you know how to schedule follow-up appointments with this doctor?

Do you know how and where to get the medicine the doctor prescribed?

d. Do you know how to make sure the child gets to the follow-up appointments?

e. Do you know how the child is supposed to take this medicine?

f. Do you know who is in charge of making sure s/he takes the medicine correctly?

If Yes, describe here:

g. Do you know what to do if the child has a bad reaction to the medicine?

List below anything else you want the judge to know.

Yes

Fill out questions 15–23 ONLY if the child is taking psychotropic medicine now
If the child is not taking this/any psychotropic medicine now, skip to question 24.

Does the medicine affect the child’s school or ability to learn?

Yes

Don’t know

Does the medicine affect the child’s ability to concentrate?

Yes

Don’t know

If Yes, describe here:

If No, describe here:

Does the child have reasonable energy levels throughout the day?

Yes

Don’t know

18 Does the medicine affect the child’s participation in hobbies or after-school activities?

Yes

Don’t know

If Yes, describe here:

Rev. January 1, 2018

Statement About Medicine Prescribed

JV-219, Page 3 of 4

Child's name:

Case Number:

19 Is it easy to get the child to take the medicine?

Yes

Don’t know

If No, describe what it’s like:

20 Does anyone talk to the child about how he or she feels when he or she is on this medicine?

Yes

Don’t know

If Yes, explain who and how often:

Has the child’s weight changed with this medicine?

Yes

Don’t know

If Yes, check one:

Lost weight

Gained weight

How many pounds?

22 List any other side effects from the medicine:

Headache

Constipation

Problems sleeping

Feeling very sleepy

Confusion

Nausea

Feel dizzy

Other (list any other side effects here):

List any benefits you have noticed from the child’s taking this medicine:

Check here if you are going to add extra pages to this form. And say how many pages:

Date:

Type or print your name

Sign your name

Rev. January 1, 2018

Statement About Medicine Prescribed

JV-219, Page 4 of 4

Statement About Medicine Prescribed

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): 119
Average fields per page: 29
Reading Level: Grade 6
LIST Grouping(s): HE-00-00-00-00, TO-02-00-00-00, ES-05-00-00-00, HE-05-00-00-00, FA-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_field_name_cb was topmostSubform[0].Page1[0].FieldName_cb[0] (0.38 conf)
topmost_subform_page_childsname_tf__1 was topmostSubform[0].Page1[0].childsname_tf[0] (0.40 conf)
topmost_subform_page_item_cb__1 was topmostSubform[0].Page1[0].item2_cb[0] (0.40 conf)
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topmost_subform_page_item_c_cb__3 was topmostSubform[0].Page2[0].item12c_cb[2] (0.40 conf)
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topmost_subform_page_item_flnslpy_cb was topmostSubform[0].Page4[0].item22flnslpy_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_page_case_number_ft__1
topmost_subform_page_item_describe_tf__1
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