Caliente Youth Center Policy Manual: Policy 12-11 s1

ATTACHMENT E………………………DCFS Initial Children’s Mental Health Psychotropic Medication Consent Form

DCFS Children’s Mental Health Policy 7.10 Attachment E 03/01/11 Division of Child and Family Services Children’s Mental Health INITIAL PSYCHOTROPIC MEDICATION CONSENT Today’s Date ______Child Name ______DOB ______Sex M F Medication Allergies ______Prescribing Physician Name ______Phone Number ______DCFS Program ______DCFS Provider ______Phone Number ______Only the medications that the client is currently taking and any additional medication that the psychiatrist is prescribing will be documented. All other medications are not applicable to informed consent. CODES C – Child currently on this medication and continuation is recommended A – Psychiatrist is recommending this medication to be added to regimen D – Child currently on medication, but it is being discontinued

Code Trade Name Generic Name FDA Approved Age Medication Rationale Combination Antipsychotic and Antidepressant Medication Symbyax (Prozac fluoxetine & olanzapine 18 and older & Zyprexa) Antipsychotic Medications Abilify aripiprazole 13 and older for schizophrenia; 10 and older for bipolar I; 6 to 17 for autism; Clozaril clozapine 18 and older Fanapt iloperidone 18 and older fluphenazine fluphenazine 18 and older (generic only) Geodon ziprasidone 18 and older Haldol haloperidol 3 and older Invega paliperidone 18 and older Loxitane loxapine 18 and older Moban molindone 18 and older Navane thiothixene 18 and older Orap pimozide 12 and older (for Tourette's syndrome) perphenazine perphenazine 18 and older (generic only) Risperdal risperidone 13 and older for schizophrenia; 10 and older for bipolar mania; 5 to 16 for autism (irritability) Saphris asenapine 18 and older Seroquel quetiapine 13 and older for schizophrenia; 10 to 17 years for bipolar mania DCFS Children’s Mental Health Page 1 of 4 Policy 7.10 Attachment E 03/01/11 Stelazine trifluoperazine 18 and older Thorazine chlorpromazine 18 and older Zyprexa olanzapine 18 and older Code Trade Name Generic Name FDA Approved Age Medication Purpose Antidepressant Medications (also used for anxiety disorders) Anafranil clomipramine 10 and older (for (tricyclic) OCD only) Asendin amoxapine 18 and older Aventyl (tricyclic) nortriptyline 18 and older Celexa (SSRI) citalopram 18 and older Cymbalta (SNRI) duloxetine 18 and older Desyrel trazodone 18 and older Effexor (SNRI) venlafaxine 18 and older Elavil (tricyclic) amitriptyline 18 and older Emsam selegiline 18 and older Lexapro (SSRI) escitalopram 18 and older; 12- 17(major depressive disorder) Ludiomil maprotiline 18 and older (tricyclic) Luvox (SSRI) fluvoxamine 8 and older (for OCD only) Marplan (MAOI) isocarboxazid 18 and older Nardil (MAOI) phenelzine 18 and older Norpramin desipramine 18 and older (tricyclic) Pamelor nortriptyline 18 and older (tricyclic) Parnate (MAOI) tranylcypromine 18 and older Paxil (SSRI) paroxetine 18 and older Pexeva (SSRI) paroxetine-mesylate 18 and older Prozac (SSRI) fluoxetine 8 and older Remeron mirtazapine 18 and older Sarafem (SSRI) fluoxetine 18 and older for PMDD Sinequan doxepin 12 and older (tricyclic) Surmontil trimipramine 18 and older (tricyclic) Tofranil (tricyclic) imipramine 6 and older (for bedwetting) Tofranil-PM imipramine pamoate 18 and older (tricyclic) Vivactil (tricyclic) protriptyline 18 and older Wellbutrin bupropion 18 and older Zoloft (SSRI) sertraline 6 and older (for OCD only) Mood Stabilizing and Anticonvulsant Medications Depakote divalproex sodium (valproic 2 and older (for acid) seizures) Eskalith lithium carbonate 12 and older Code Trade Name Generic Name FDA Approved Age Medication Purpose Gabitril tiagabine 12 and older (for DCFS Children’s Mental Health Page 2 of 4 Policy 7.10 Attachment E 03/01/11 seizures) Keppra levetiracetam 12 and older (for seizures) Lamictal lamotrigine 18 and older lithium citrate lithium citrate 12 and older (generic only) Lithobid lithium carbonate 12 and older Neurontin gabapentin 18 and older Tegretol carbamazepine any age (for seizures) Topamax topiramate 18 and older Trileptal oxcarbazepine 4 and older Anti-Anxiety Medications (benzodiazepines, except BuSpar) Ativan lorazepam 18 and older BuSpar buspirone 18 and older Dalmane Flurazepam 18 and older Klonopin clonazepam 18 and older Librium chlordiazepoxide 18 and older oxazepam oxazepam 18 and older (generic only) Restoril temazepam 18 and older Tranxene clorazepate 18 and older Valium diazepam 18 and older Xanax Alprazolam 18 and older ADHD Medications (all stimulants, except Straterra, Catapres, Intuniv, and Tenex) Adderall amphetamine 3 and older Adderall XR amphetamine (extended 6 and older release) Catapres clonidine unknown Concerta methylphenidate (long acting) 6 and older Daytrana methylphenidate patch 6 and older Dexedrine dextroamphetamine 3 and older Dextrostat dextroamphetamine 3 and older Focalin dexmethylphenidate 6 and older Focalin XR dexmethylphenidate(time 6 and older release) Intuniv guanfacine 6 and older Metadate ER methylphenidate (time 6 and older release) Metadate CD methylphenidate(time 6 and older release) Methylin methylphenidate(solution/che 6 and older wable) Ritalin methylphenidate 6 and older Ritalin SR methylphenidate (time 6 and older release) Ritalin LA methylphenidate (long-acting) 6 and older Code Trade Name Generic Name FDA Approved Age Medication Purpose Strattera atomoxetine 6 and older Tenex guanfacine 6 and older Vyvanse lisdexamfetamine dimesylate 6 and older Other

DCFS Children’s Mental Health Page 3 of 4 Policy 7.10 Attachment E 03/01/11 Disclaimer: This list may not be all-inclusive due to new medication additions/changes. This list is a resource to help determine need for further medication review, obtaining consent and monitoring for child well being as required by statewide policy #### (NRS 432B.197). ~ Last updated 7/1/2010. Additional update information may be available at: http://www.nimh.nih.gov/health/publications/mental-health-medications/alphabetical- list-of-medications.shtml

My signature on this form means that items 1-8 below are fully understood: 1. The diagnosis and target symptoms for the medication(s) being prescribed. 2. The medication(s) risks, side effects, benefits and treatment alternatives. 3. The proposed course and length of treatment. 4. The possibility that medication dosages may need to be adjusted over time in consultation with the medical practitioner. 5. The intended outcome of treatment. 6. Possible clinical indications to suspend or terminate treatment. 7. The right to withdraw informed consent at any time and the potential consequences of such action. 8. A Psychotropic Medication Consent form will be required each time a psychotropic medication(s) is prescribed.

Parent Date

Child Welfare Agency Representative (if child in the custody of a child welfare agency) Date

Physician Signature Date

Parent Refused to Consent

Parent Unavailable (explain):______

For Desert Willow Treatment Center, Oasis On Campus Treatment Homes, Adolescent Treatment Center and Family Learning Homes only:

Parent/guardian unavailable in person. This form was read to them and they gave verbal consent. I informed the parent/guardian that follow-up written consent must be obtained in no more than two weeks and made arrangements for this to occur.

______Staff Name (Print) Staff Signature Date

______Staff Witness Name (Print) Staff Witness Signature Date

DCFS Children’s Mental Health Page 4 of 4 Policy 7.10 Attachment E 03/01/11