Prescribing Practitioner

*Name (First) (Last)
*Specialty
*Address
*City
*Zip
*Phone -- ext
If prescribing provider’s email information is provided, we will send an e-mail notification.
Email

Section 1: Demographic Information

*Date of Office Visit
*Type of Visit Other:
Previous Preconsent Reviews Numbers
Please provide previous Preconsent Reviews Numbers, if known
*Child's Name (First) (MI) (Last)
*Child's Date of Birth *Age: Calculate Age
*Height (enter height in inches, not feet plus inches)
*Weight (enter weight in pounds, not kilograms)
IMPORTANT: Updated information on height and weight is necessary for completing the preconsent review, as many medications are prescribed on basis of weight, and may affect height and weight.
*BMI Calculate BMI
*Gender Male Female
*County
*Circuit
*Name of submitter
*Phone -- ext
*Fax --
Only if faxing is requested
*Email
Case Manager /
Child Welfare Staff
(enter only if not the preconsent submitter)
Phone -- ext
Fax --
Email

(A copy of the report and e-mail notification of fax will be sent to the addresses above, if provided)
Case Manager
Supervisor
Phone -- ext
Contracted Agency
Obtaining Informed Consent was attempted from the parent/guardian: Yes No Date

Section 2: Diagnosis / Disorder / Behavioral Hypothesis

*Select all that apply

ADHD
Anxiety Disorder
Autism Spectrum Disorder
Bipolar or Related Disorder
Communication/Speech/Language Disorder
Conduct Disorder
Depressive Disorder
Disruptive Mood Dysregulation Disorder
Learning Disorders
Intellectual Disability
OCD
Oppositional Defiant Disorder
Post Traumatic Stress Disorder
Psychosis
Reactive Attachment Disorder
Schizophrenia
Substance-Related or Addictive Disorder
Tics/Tourette's Disorder
Other
Rule Out:

Section 3: Psychotropic Medication Planned

*Medication

New Medication
Requesting authorization on existing medication

*Dose Amount: Unit:
Route:
Frequency:
*Dosage range Starting dose: Amount Unit:
Maximum dose: Amount Unit:
Titration plan Increase dose by Unit: at the following schedule until target dose is achieved or target symptoms are alleviated.
*To address the
following target
symptoms

Select all that apply

Aggression
Anxiety
Compulsions
Depression
Dysphoria
Hallucinations
Hyperactivity
Impulsivity
Inattention
Irritability
Mood Instability
Obsessions
Self-injurious Behavior
Stereotypies
Thought Disorder
Tics
Other
*Define treatment
success

Select all that apply

Decreased frequency/duration of tantrums
Decreased frequency/intensity of aggressive episodes
Increased ability to attend school/daycare
Increased ability to participate in social activities
Increased social relatedness
Improved caregiver-child relationship
Reduction in target symptoms as measured by appropriate symptom assessment measures (e.g., SNAP/Vanderbilt score or CDI)
Other
*Define
monitoring plan

Selet a monitoring plan and edit if necessary, or select the blank box and write your own

For any other information about the medication you want to provide

Section 4: Other Planned Treatments / Therapies / Evaluations

*Select all that apply

Applied behavior analysis
Behavior modification
Cognitive behavioral therapy
Family therapy
Psychoeducational testing
Speech/language assessment
Parent/caregiver training in behavior management
Other

Section 5: Medical Problems and Other Medications (including over the counter medications)

*Physical exam

Physical exam completed and normal
Physical exam completed and following abnormalities:

*Medical Problems

No other medical problems

Allergy or asthma
Heart problems
Gastro-intestinal problems
Seizures
Other

Is the child currently on other psychotropic medications?

(Use only if a preconsent was already obtained, otherwise add in Section 3)

1) Amount: Unit: Frequency:
Range:

2) Amount: Unit: Frequency:
Range:

3) Amount: Unit: Frequency:
Range:

4) Amount: Unit: Frequency:
Range:

Is the child on any other non-psychotropic medications (including over the counter)?

1) 2)