Superior Court Of The State Of California For The County Of Los Angeles (Page 2 of 4) in pdf

Superior Court Of The State Of California For The County Of Los Angeles Page 2

4. In my professional judgment the patient would benefit from the administration of the

following classes of psychiatric medications:

______________________________________________________________________________

_____________________________________________________________________________.

5. I declare further that I have explained or attempted to explain to the patient the risks,

benefits, possible side effects and treatment alternatives as described in Welfare and Institutions

Code Section 5213(b) and to obtain the patient's consent to receive medication: (Insert dates

and description of each explanation or attempted explanation and the dates these were

charted)

_____________________________________________________________________________

_____________________________________________________________________________.

6. The patient's responses to these efforts were the following: (Verbatim, if possible)

______________________________________________________________________________

_____________________________________________________________________________.

7. It is my professional opinion that the patient is not able to give informed consent to the

recommended medication because:

A) The patient [ ] is aware [ ] is not aware of his/her mental disorder; (Explain)

______________________________________________________________________________

Page 2 of 4

Rev. 9/6/13

Superior Court Of The State Of California For The County Of Los Angeles Page 2