Form Mpc 800 - Clinician'S Affidavit As To Competency And Treatment (Page 2 of 5) in pdf

Form Mpc 800 - Clinician'S Affidavit As To Competency And Treatment Page 2

8. The Respondent continues to suffer from the effects of the clinically diagnosed condition. Specifically, the Respondent's

behavior is as follows:

9. It is my opinion that adequate treatment of this Respondent requires the administration of antipsychotic medication as set

forth in this affidavit.

COMPETENCY

10. I have discussed with the Respondent the risks and benefits of the proposed plan of treatment. It is my opinion that the

Respondent does not have the present ability to make informed decisions with respect to personal affairs; specifically,

those decisions regarding psychiatric treatment, including, but not limited to, the ability to make informed decisions

regarding treatment with antipsychotic medication with the following exceptions, if any:

11. I base this conclusion on my observations and examination of the Respondent and upon the following specific facts noted

in the course of those observations and examinations:

12. The Respondent is:

currently accepting treatment with the following antipsychotic medication:

MEDICATION

DOSAGE AND DOSE RANGE

actively refusing to accept treatment with antipsychotic medication. The Respondent's stated reasons are as follows:

PROPOSED TREATMENT

13. The Respondent

has not

previously been administered antipsychotic medication. If Respondent

has

has been treated with antipsychotic medications, the history of that treatment is as follows:

14. The following is a list of antipsychotic medications which were administered to the Respondent but discontinued due to

negative side effects or lack of efficacy:

None.

As follows:

MPC 800 (6/17/11)

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Form Mpc 800 - Clinician'S Affidavit As To Competency And Treatment Page 2