Form Cfs 431-A - Psychotropic Medication Request Form - Illinois Department Of Children & Family Services

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CFS 431-A
Rev 12/2011
 Illinois Department of Children & Family Services  
PSYCHOTROPIC MEDICATION REQUEST FORM  
Child’s Name ___________________________DCFS ID# (8digits) __ __ __ __ __ __ __ __    Male   Female    Date _____________ 
 
Date of Birth ______________
Ethnicity _________ 
If 18 or older, include either consent from youth or con nued guardianship court order   
Placement type:   Foster Home  Residen al  Hospital   Family of Origin  Shelter  DOC  Other______________________  
Facility or Agency Name _______________Contact Person __________________Phone ___________________Fax ______________ 
Prescriber ____________________________Specialty ________________ Phone __________________ Fax ___________________ 
Clinical Informa on
Psychiatric Diagnoses (include r/o): _______________________________________________________________________________ 
____________________________________________________________________________________________________________ 
Medical Diagnoses: ____________________________________________________________________________________________ 
 
Current weight _______  Current height _______ 
  Current Psychotropic Medica ons                                 No Current Meds 
Date wt. and ht. last taken _____________ 
*include all current meds & dosages, meds on without consent and those being renewed 
______________________________________________________ to be discon nued 
Tests to be Monitored:  Include Results and Date 
Medica on                   Dosage                      Time Given 
 FBS _____________ HgAIC_______________  
______________________________________________________ to be discon nued 
Medica on                   Dosage                      Time Given 
 Lipids ___________  Na _________________  
______________________________________________________ to be discon nued 
Medica on                   Dosage                      Time Given 
 K+______________  Mg++_______________  
______________________________________________________ to be discon nued 
 EKG____________  VPA level _____________ 
Medica on                   Dosage                      Time Given 
______________________________________________________ to be discon nued 
 LiCO3 level __________  CBZ level _________ 
Medica on                   Dosage                      Time Given 
______________________________________________________ to be discon nued 
 LFT’s _____________  TFT’s ______________ 
Medica on                   Dosage                      Time Given 
  Kidney ____________Other: _____________ 
______________________________________________________ to be discon nued 
Medica on                   Dosage                      Time Given 
Will Monitor:  Include Comments and Plan
 
Past trials/reason for discon nua on:_________________________________________ 
 Adequate Growth ________________________ 
_______________________________________________________________________ 
 Excessive Wt. Gain _______________________ 
_______________________________________________________________________ 
 AIMS/DISCUS____________________________ 
Other current medical medica ons, over the counter and supplements: _____________ 
 Other __________________________________ 
_______________________________________________________________________
_ 
 
Medica on Request
(all fields required for processing)
Type of request:   New   Increase  Renewal (consent to expire)   Resume (prior trial)  New ward, current med   One Time Order              
 Emergency med (for acute sx’s)   On med or dosage w/o consent; Prescriber who started med  ______________Date started ___________  
_______ 
Medica on __________________________ Dosage __________Times Given _______________ Range 
Form_______ Dura on ________         
                           
   
 180 
 
Symptoms/Behaviors for this medica on (do not list diagnoses, acute = current; remi ed = controlled on medica on): 
 This  Medica on is to treat acute symptoms; List Current Symptoms: ______________________________________________________________ 
________________________________________________________________________________________________________________________ 
  This Medica on is for maintenance treatment; List Remi ed Symptoms:___________________________________________________________ 
________________________________________________________________________________________________________________________ 
Addi onal ra onale for co‐pharmacy, non‐first‐line medica ons, polypharmacy and other significant clinical informa on i.e. explana on of the 
treatment plan or  history, alterna ve treatments (required for children <8), e ology of sleep disturbance. List all current adverse/side effects. 
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________ 
Side effects for all medica ons 
YES 
 Does child object 
YES  
 
reviewed with child? 
NO 
to the medica on? 
NO 
IF YES, LIST MEDICATION AND EXPLAIN WHY CHILD OBJECTS 
Form  
Number of  
MD Office Facility  Staff   DCFS worker  POS worker  Agency  Other_____________________ 
Completed  by: 
____ 
pages: _
 Name __________________________________Phone ___________________   Fax _________________ 
1 

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