ࡱ> y v bjbj . {{_3E4&4&4&4&4&$X&X&X&Pr`s,X&>&++++, -"- :======$@C=4&.-,,.-.-=4&4&++4>v3v3v3.-F4&+4&+:v3.-:v3v3U66+ it-m6:>0>u6,XDt-XD6XD4&6.-.-v3.-.-.-.-.-==r0.-.-.->.-.-.-.-XD.-.-.-.-.-.-.-.-.- $: PSYCHOTROPIC MEDICATION INFORMED CONSENTMichigan Department of Human ServicesDate of appointment: FORMTEXT      Section A  Psychotropic medication recommendation: (to be completed by licensed medical professional)Identifying Information: Please PrintChild name:Date of birth: FORMTEXT       FORMTEXT      Sex:Height:Weight: FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT       FORMTEXT      Prescribing health care provider:Telephone number: FORMTEXT      ( FORMTEXT    )  FORMTEXT      FORMTEXT     Office/Facility name:Office/Facility address: FORMTEXT       FORMTEXT      Clinical information:Concurrent medical diagnoses: FORMTEXT      All mental health diagnoses: FORMTEXT      All current psychotropic medications:Medication/dosage/administration scheduleMedication/dosage/administration scheduleMedication/dosage/administration schedule FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Discontinued psychotropic medication: FORMTEXT      New medications and recommendations: (not necessary for dosage changes within current prescribed dosage range)Name of medication #1:Dosage RangeFrequency of administration FORMTEXT       FORMTEXT       -  FORMTEXT       FORMTEXT      Target symptoms/benefits:Potential Side effects: FORMTEXT       FORMTEXT      Rationale (Required only if prescribed medication falls within Criteria Triggering Further Review (see bottom of pg. 2)1 FORMTEXT      Tests/procedures required before/during medication regimen:Alternative treatments: FORMTEXT       FORMTEXT      Review of Above Information:With child:With foster parent/current foster care placement:Foster parent(s) name: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT      If child is a temporary court ward was the information above reviewed with Legal Parent(s)/Guardian: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, method of review: FORMCHECKBOX In-person FORMCHECKBOX TelephoneName of medication #2 (use another DHS-1643 for 3 or more medications):Dosage RangeFrequency of administration FORMTEXT       FORMTEXT       -  FORMTEXT       FORMTEXT      Target symptoms/benefits:Potential Side effects: FORMTEXT       FORMTEXT       Rationale (Required only if prescribed medication falls within Criteria Triggering Further Review (see bottom of pg. 2)1 FORMTEXT      Tests/procedures required before/during medication regimen:Alternative treatments: FORMTEXT       FORMTEXT      Review of Above Information:With child:With foster parent/current foster care placement:Foster parent(s) name: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT      If child is a temporary court ward was the information above reviewed with Legal Parent(s)/Guardian: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, method of review: FORMCHECKBOX In-person FORMCHECKBOX TelephoneSignature(Prescribing licensed medical professional)(Date)DHS Psychotropic Medication Informed ConsentSection B Notification (to be completed by caseworker):Child Name:DOB:Legal Status: FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX Legal parent(s) were notified of psychotropic medications FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Child is a state ward.For Temporary Court Wards medication cannot be administered until signed consent is received from parent/legal guardian or the court.Comments FORMTEXT      Caseworker Name:Agency/DHS Local Office FORMTEXT       FORMTEXT      Address:Phone Number: FORMTEXT      ( FORMT  N P R f h j t v x z    . 0 ܾܾܐ܁ܐv܁njhwUjhseUhwj!hseUhseh h 5jh'4U h?V,h jih'4Uh'4jh'4U h%th{?h%th{?5 h?V,h{?jhseUjh{?Ujh{?U h{?5h{?+RTmd[dd E$Ifgdse G$IfgdKG?kdV$$Ifl4,,4 lalf4ytw '$Ifgd{??kd$$Ifl4,,4 lalf4ytw *$Ifgd{?  }.% G$Ifgd%tOkd$$Ifl4,,  4 lalf4p yt b 0$Ifgd%txkd $$Ifl4\boi!,b . 4 lalf4yt8  0 N P x cZZ E$IfgdseRkd$$Ifl40i!,i!. 4 lalf4yt8 G$IfgdKG?kd$$Ifl4,,4 lalf4yt8 =ekd$$Ifl4F,    4 lalf4ytw G$IfgdKGRkd=$$Ifl40i!,i!. 4 lalf4ytw . 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I have been informed of the nature of my condition, the risks and benefits or treatment with the medications, of other forms of treatment, as well as the risks of no treatment.Foster Parents cannot consent to administration of psychotropic medications FORMCHECKBOX By signing below, I give consent forto receive the medicationslisted in section A, as recommended by his/her licensed health care provider. I understand that I can withdraw this consent for my child to receive medications at any time during his/her treatment. FORMCHECKBOX By signing below, I do not give consent forto receive the medicationslisted in section A, as recommended by his/her licensed health care provider. Reason consent denied:2Authorized SignatureDateRelationship to Child:Print Name:Section C  Consent for administration of psychotropic medications (signed by youth age 18 or older):I have been informed of the recommendation to prescribe medications as part of my treatment. I have been informed of the nature of my condition, the risks and benefits or treatment with the medications, of other forms of treatment, as well as the risks of no treatment.SignatureDateA new signed consent is required once a year, when a new medication is started and/or when the dosage exceeds the maximum indicated in the dosage range.Criteria Triggering Further Review FORMCHECKBOX Prescribed four or more concomitant psychotropic medications FORMCHECKBOX Prescribed two or more concomitant anti-depressants. FORMCHECKBOX Prescribed two or more concomitant anti-psychotics. FORMCHECKBOX Prescribed two or more concomitant stimulant medications. FORMCHECKBOX Prescribed two or more concomitant mood stabilizer medications. FORMCHECKBOX Prescribed psychotropic medications in doses above recommended doses FORMCHECKBOX Prescribed psychotropic medication and child is five years or younger.1 To the physician: In compliance with the MDHS Guidelines for the Use of Psychotropic Medication for Children in State Custody, the above medication combinations should be avoided. These parameters do not necessarily indicate treatment is inappropriate, but for DHS purposes further review is needed. Check the appropriate box if any apply. An explanation must be provided within the rationale section (under the Medications on pg.1), and you may be contacted for follow up. 1 To the caseworker: If the Rationale field in section A is completed and one or more of the check boxes are checked, a copy of the completed Psychotropic Medication Consent Form must be faxed to the DHS Health, Education & Youth Unit at 517-335-7789. 2If consent is denied and all other parties agree medication is needed, a court order is necessary for medication to be administered. Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.     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