CFS 431-A: Psychotropic Medication Request

Please read the instructions below prior to completing the request. Failure to follow instructions may result in a processing delay.

Instructions:
This form should be completed by a medical professional. All Psychotropic Medication requests will be reviewed by our Clinical Services in Psychopharmacology (CSP) Consultant. Please ensure you fill out all fields in their entirety to minimize processing delays.

Please be aware of the following when completing the form:
1. Do not use acronyms anywhere in the request.
2. Please ensure the return email and/or fax number is correct to allow for return of the completed consent.
3. Please attach any lab work, medication logs, or supporting documentation with this request submission.
4. If a request is for a new youth in care of the State of Illinois, please attach the court order and include the DCFS ID number given, if known.

For one-time emergency medication requests, the following is required:
1. Provide the administration date and time given of the emergency medication in the 'Other Dosage and Time Given' field.
2. Provide the dose administered in the 'Max Daily Range' field.

To determine the Youth's BMI, please use the following calculator: CDC BMI Calculator

Form Submission

Requestor Information

Form Completed By

If other, please specify

Facility or Agency Name

First Name

Last Name

Please use an Illinois.gov email if possible. The completed consent will be returned to this email.

Phone Number

Please provide a direct phone number, and phone extension if applicable, where the requestor can be reached in case additional information is needed to process the request.

Phone Extension

***

Fax

Office of the Guardian - Consent Unit

Office of the Guardian - Consent Unit