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 (STAT) Medication requests, please note the following:
1. One Time Emergency Medication requests must be submitted separately from other types of medication requests (e.g., New, Increase, Renewal or New to DCFS continuing medication)
2. Clinical Information and Current Psychotropic Medication(s) are not required for One Time Emergency Medication submissions.
3. On the Medication Request step, choose ‘One Time Emergency Medication’ and the required fields will appear. You must indicate the medication name, form, dose, date and time administered, and symptoms leading to the administration of the medication.
To determine the Youth's BMI, please use the following calculator: CDC BMI Calculator
