Here is the text we could read:
JV-217-INFO
Guide to Psychotropic Medication Forms
Use these Judicial Council forms to ask for an order to give (or to continue giving) psychotropic medication to a child who is
a ward or a dependent of the juvenile court and living in an out-of-home placement or in foster care, as defined in Welfare
and Institutions Code section 727.4. Local forms may be used to provide additional information to the court.
Exception: These forms are not required in these situations:
•
If the child lives in an out-of-home facility not considered foster care, as defined by section 727.4, unless a local court rule
requires it; or
If there is a previous court order that gives the child’s parent(s) or guardian(s) the authority to approve or refuse the
medication.
•
Required Forms
Optional Forms
JV-220
JV-220(A)
JV-220(B)
JV-221
JV-223
JV-224
Application for Psychotropic Medication
Physician’s Statement—Attachment
Physician’s Request to Continue Medication—
Attachment
Proof of Notice of Application
Order on Application for Psychotropic Medication
County Report on Psychotropic Medication
The parent, guardian, child, caregiver, CASA, or Indian tribe
wanting to give input to the court may use one of these forms:
JV-218
JV-219
Child’s Opinion About the Medicine
Statement About Medicine Prescribed
A person who opposes the proposed medication or who wants
to give the court more information may fill out this form:
JV-222
Input on Application for Psychotropic Medication
Required Forms
1 Form JV-220, Application for Psychotropic
Medication
This Application gives the court basic information about
the child and his/her living situation. It also provides
contact information for the child’s social worker or
probation officer.
This form is usually completed by the social worker or
probation officer, but is sometimes completed by the
prescribing physician or his/her staff, or the child’s
caregiver.
Whoever completes the form must identify him/herself by
name and by signing the form. If the prescribing physician
completes this form, s/he must also complete and sign
form JV-220(A) or form JV-220(B). (See below.)
2 Form JV-220(A), Physician’s Statement—
Attachment
This form must be used to ask the court for a new order. It
can also be used to request to continue medication. The
prescribing doctor fills out this form then gives it to the
person who files the Application (form JV-220).
This form provides a record of the child’s medical history,
diagnosis, previous treatments, and information about the
child’s previous experience with psychotropic
medications. The doctor will list his/her reasons for
recommending the psychotropic medications.
Emergencies: A child may not receive psychotropic
medication without a court order except in an emergency.
A doctor may administer the medication on an emergency
basis. For a case to qualify as an emergency, the doctor
Judicial Council of California, www.courts.ca.gov
Revised January 1, 2019, Optional Form
Welfare and Institutions Code, §§ 369.5, 739.5
California Rules of Court, rule 5.640
must find that the child’s mental condition requires
immediate medication to protect him/her or others from
serious harm or significant suffering, and that waiting for
the court’s authorization would put the child or others at
risk. After a doctor administers emergency medication,
s/he has two days at most to ask for the court’s
authorization.
3 Form JV-220(B), Physician’s Request to Continue
Medication—Attachment
This is a shorter version of form JV-220(A). It may be used
only by the same doctor who filled out the most recent
form JV-220(A) if s/he is prescribing the same medication
with the same maximum dosage. The prescribing doctor
fills out this form then gives it to the person who is filing
the Application (form JV-220).
4 Form JV-221, Proof of Notice of Application
This form shows the court that all parties with a right to
receive notice were served a copy of the Application and
attachments, according to rule 5.640 of California Rules of
Court.
The person(s) in charge of notice must fill out and sign this
form. A separate signature line is provided on each page of
the form to accommodate those courts in which the
provision of notice is shared between agencies. This occurs
when local practices or local court rules require the child
welfare services agency to provide notice to the parent or
legal guardian and the caregiver, and the juvenile court
clerk’s office to provide notice to the attorneys and CASA
Guide to Psychotropic Medication Forms
JV-217-INFO, Page 1 of 2
JV-217-INFO
Guide to Psychotropic Medication Forms
volunteer. If one agency does all the required noticing,
only one signature is required on page 3 of the form. The
person(s) in charge of service should use the fastest
method of service available so that people can be served
on time. Electronic service of these forms is not permitted.
(Welf. & Inst. Code, § 212.5)
5 Form JV-223, Order on Application for Psychotropic
Medication
This form lists the court’s findings and orders about the
child’s psychotropic medications. The agency or person
who filed the Application must provide the child’s
caregiver a copy of the court order approving or denying
the Application.
The copy of the order must be provided (in person or by
mail) within two days of when the order is made.
If the court approves the Application, the copy of the order
must include the last two pages of form JV-220(A) or
JV- 220(B), and all of the medication information sheets
(medication monographs) that were attached to form
JV-220(A) or JV-220(B).
If the child’s placement is changed, the social worker or
probation officer must provide the new caregiver with a
copy of the order, the last two pages of form JV-220(A) or
JV-220(B), and all of the medication information sheets
(medication monographs) that were attached to form
JV-220(A) or JV-220(B).
6 Form JV-224, County Report on Psychotropic
Medication
The social worker or probation officer must complete and
file this form before each progress review. It has
information that the court must review, including the
caregiver’s and child’s observations about the medicine’s
effectiveness and side effects, information on medication
management appointments and other follow-up
appointments with medical practitioners, and information
on the delivery of other mental health treatments.
This form must be filed at least 10 calendar days before
the progress review hearing. If the progress review is
scheduled for the same time as a status review hearing, the
form must be attached to and filed with the court report.
Optional Forms
7 Form JV-218, Child’s Opinion About the Medicine
The child may use this form to tell the judge about him/
herself and his/her opinion about the medicine.
The child may ask someone s/he trusts for help with the
form.
The child may also tell the judge how s/he feels in person
at the hearing, by letter, or through his social worker,
probation officer, lawyer, or CASA.
8 Form JV-219, Statement About Medicine Prescribed
The parent, guardian, caregiver, CASA, or Indian tribe
may use this form to tell the court how they feel about the
Application, and the effectiveness and side effects of the
medicine.
This form must be filed within four court days of receipt
of the notice of an Application, or before any status review
hearing or medication progress review hearing.
This form is not the only way for the parent, guardian,
caregiver, CASA, or tribe to provide information to the
court. They can also provide input on the medication by
letter; by talking to the judge at the court hearing; or
through the social worker, probation officer, attorney of
record, or CASA. A CASA can also file a report under
local rule.
9 Form JV-222, Input on Application for Psychotropic
Medication
This form may be used when the parent or guardian,
attorney of record for a parent or guardian, child, child’s
attorney, child’s CAPTA guardian ad litem, or Indian
child’s tribe does not agree that the child should take the
recommended psychotropic medication. This form may
also be used to provide input to the court.
Within four court days of service of notice of the pending
application regarding psychotropic medication, the parent
or guardian, his or her attorney, the child, the child’s
attorney, the child’s CAPTA guardian ad litem, or the
Indian child’s tribe that disagrees must complete, sign,
and file form JV-222 with the clerk of the juvenile court.
The court will make a decision about the child’s
psychotropic medication after reading the Application, its
attachments, and all statements filed on time. The court is
not required to set a hearing if a statement opposed to
medication is filed.
If the court does set the matter for a hearing, the juvenile
court clerk must provide notice of the date, time, and
location of the hearing to the parents or legal guardians,
their attorneys, the child if 12 years of age or older, the
child’s attorney, the child’s current caregiver, the child’s
social worker, the social worker’s attorney, the child’s
CAPTA guardian ad litem, the child’s CASA, if any, and
the Indian child’s tribe at least two court days before the
hearing date. In delinquency matters, the clerk also must
provide notice to the child regardless of his or her age, the
child’s probation officer, and the district attorney.
Rev. January 1, 2019
Guide to Psychotropic Medication Forms
JV-217-INFO, Page 2 of 2
