Prescribing Practitioner

*Name (First) (Last)
*Specialty
*Address
*City
*Zip
*Phone -- ext
*Fax --
*Email
(A copy of the report and e-mail notification of fax will be sent to the address above)

Section 1: Demographic Information

*Date of Office Visit
*Child's Name (First) (MI) (Last)
*Child's Date of Birth *Age: Calculate Age
*Height (inches)
*Weight (pounds)
*BMI Calculate BMI
*Gender Male Female
*County
*Circuit
Name of submitter
(if not provider or case manager)
Phone -- ext
Fax --
Email
Case Manager /
Child Welfare Staff
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/Asperger's
Bipolar Disorder
Communication/Speech
Conduct Disorder
Depression
Learning Disorders
Intellectual Disability
Oppositional Defiant Disorder
Post Traumatic Stress Disorder
Psychosis
Reactive Attachment Disorder
Substance Abuse
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

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
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)