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
*Phone -- ext
*Fax --
*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/Asperger's
Bipolar Disorder
Communication/Speech/Language Disorder
Conduct Disorder
Depression
Disruptive Mood Dysregulation Disorder
Learning Disorders
Mood Disorder, not otherwise specified
Intellectual Disability
OCD
Oppositional Defiant Disorder
Post Traumatic Stress Disorder
Psychosis
Reactive Attachment Disorder
Schizophrenia
Substance Abuse
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)