Section l: Demographics:

  1. Child’s Name: Correct spelling of name, aliases, and hyphenated last names; do not assume all names are spelled the same, i.e., John or Jon.
  2. DCFS I.D. #: Is an 8digit number that would not end in 00
  3. Date of Birth: Age can determine appropriate use and dosage of a medication. It is also useful in assessing proper growth and development. Consultations are accepted for DCFS wards under the age of 18 years old unless DCFS has been given authority to consent for meds in a court of law.
  4. Gender: Some names are not gender specific. There are some side effects that should be reported to DCFS that are gender specific.
  5. Ethnicity: May influence the metabolism and possible side effects of some medications.
  6. Weight and Height: Accurate and current weight at time of consent request will be used to calculate the appropriate dose of the medication. Height is necessary to assess adequate development as some medications may effect growth.
  7. Placement: Check where the child resides at the time of the request for medication.
  8. Facility Name   The name of the facility, along with address and telephone number will assist agent to obtain up to date and correct information as quickly as possible.
  9. Prescribing Physician: Correct, legible spelling of physician name.
  10. Specialty and contact information: The prescribing physician’s area of specialty, i.e., psychiatrist, pediatrician, family practitioner, pediatric neurologist. An address and telephone number will assist agent in obtaining up to date and correct information as quickly as possible.

Section ll: Relevant Clinical Information

  1. Concurrent Medical Diagnosis: All current medical conditions, i.e., asthma, diabetes, obesity.
  2. All Psychiatric Diagnosis: All current DSM psychiatric diagnosis should be listed. Medication management follows diagnosis.
  3. All current medications and dosages: List all of the current medications and dosages, especially if medication request is for a higher dose.
  4. Discontinued Medication: List all discontinued medication and medications that will be tapered to be discontinued if the requested medication is approved.  For documentation purposes, include the reason for discontinuation (i.e. ineffective, side effects).
  5. Additional Info/other medications: A place to put your specific rationales for difficult to treat cases or other information you may feel will help us to understand the medication regimen for this child. Include medications for medical purposes as they may be contraindicated in conjunction with some psychotropic medications.
  6. Section lll: Psychotropic Medication Request
  7. Type of request

ü  New medication request for minor. New Ward that is already on medication.

ü  Increase in actual dosage or range. Must include the current dose of medication being requested.

ü  Renewal- Six-month evaluation to assess the need for continued use of the requested medication. The renewal request should consist of current symptoms or past exhibited behaviors that medication has stabilized. Give the current dosage and maximum dosage range if still indicated.

ü  Resume- A medication that was discontinued; however, symptoms indicate need for medication to be restarted.

ü  One Time Order- Emergency or Stat medication requests. Per the Mental Health and Developmental Disabilities Code (MHDD Code), emergency medications are permitted if a minor is a threat to themselves or to others. In addition to completing all the fields on this form please add route, date and time given.

Note: PRN consents are not granted by DCFS, One Time Orders are reviewed for one dose of the stated medication.

ü  New Ward, Current Medication A medication  that was started prior to  wardship and will continue under the observation of the child’s current or new M.D. and placement.

  1. Brand Name and Chemical Name Should be written legibly.
  2. Form Indicate if the medication is a tab, liquid etc.
  3. Dosage Starting dose if new, current dose if renewal, increased dose if increase.
  4. Also add dosage range if indicated.
  5. Frequency List the times the medications are being given: bid, tid, qid, qd, qhs, q2pm, etc. If the plan is to increase dosage times, list it as starting dose up to target frequency (i.e. qhs up to tid).
  6. Range May request a maximum dose for this child’s age and wt.
  7. Duration The duration of the request is for 180 days unless indicated differently by thePrescribing physician (i.e., One time orders or for 2 weeks).
  8. Symptoms or Rationale for medication requestedSymptoms should be clear and descriptive and in the case of renewals may be listed as a past history or remitted behaviors. All symptoms must correspond with the treatment requested and should refer to a psychiatric diagnosis.Rationales for co-pharmacy, poly-pharmacy or unusual medication regimes are required with each and every request. Include current Lithium Carbonate, Valproic Acid and Carbamazepine serum blood levels whenever requesting increases or renewals.Rationales
  9. Rationales should not be Drug Classifications or a Psychiatric Diagnosis.
  10. Alternative treatment methods considered/attempted and the reasons they failed or were rejected: This section allows the prescribing physician to list previous medications, therapies or behavior interventions that have been tried and/or have failed.
  11. Test/procedures required: List all pertinent tests needed to safely monitor minor on medications, i.e., EKG, serum blood levels, labs, B/P, P
  12. Potential side effects: Check if side effects have been reviewed with the child.
  13. If child is 12 years of age or older, does he/she object to medication: Per the Mental Health and Developmental Disabilities Code (MHDD Code) all children 12 years or older have the right to refuse prescribed medications
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