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Form Dd-162 - Consent For Use Of Behavior-Modifying Medications With A Behavior Treatment Plan

DD-162 (6-06)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

CONSENT FOR USE OF BEHAVIOR-MODIFYING MEDICATIONS

WITH A BEHAVIOR TREATMENT PLAN

CLIENT’S NAME (Last, First, M.I.)

BIRTHDATE

MEDICATION PRESCRIBED

DOSAGE

DATE SEEN

The above client was seen by me on the aforementioned date. I have prescribed the medication and maximum dosage as stated above,

for a period of time not to exceed 12 months from the date of my order.

REASON(S) FOR PRESCRIBING THE MEDICATION

EXPECTED BENEFITS

PROBABLE SIDE EFFECT(S)

PRECAUTIONS TO BE TAKEN

I have determined that the expected benefits outweigh the potential risks. The responsible person or any or any IPP Team Member is

invited and encouraged to attend any psychotropic medication reviews.

PHYSICIAN’S NAME (Please print)

PHONE NO.

(

)

PHYSICIAN’S SIGNATURE

DATE

NOTE: Retain this page for your records. Sign and date page 2 and return it to your DDD case manager.

Equal Opportunity Employer/Program

Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with

Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits

discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability.

The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For

example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location,

or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a

program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a

program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in

alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602 542-6825;

TTY/TDD Services: 7-1-1. ♦ Español en el reverso.