Involuntary Medication Request Form

Involuntary Medication Request Form

Precision Psychiatric Services - Penal Code 2603
Patient Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Facility
Unit and Location (ie 2B-101)
Psychiatrist completing evaluation:
Date of Evaluation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Psychiatrist Evaluation:
I have performed a Psychiatric Evaluation for the above named inmate and it is my medical opinion that the inmate suffers from a serious mental disorder (Penal Code 2603 (c)(1)).
Diagnosis based on evaluation:
Factual Basis for the Diagnosis (Penal Code 2603 (7)(A)):
In my professional opinion, as a result of the above named mental disorder the inmate is: (PC 2603 (c)(2))
Facts leading to determination of GDA/DTS/DTO: (Penal Code 2603 (7)(A))
The inmate has been prescribed one or more antipsychotic medications for the disorder and I have considered the risks, benefits, and treatment alternatives to involuntary medication. (Penal Code 2603 (c)(3))
The basis upon which psychiatric medication is recommended: (Penal code 2603 (7)(A)
Name of recommended voluntary oral medication:
The expected benefits of the medication (Penal Code 2603 (7)(A)):
The potential common side effects and risks to the inmate from the medication: (Penal Code 2603 (7)(A))

Other
Has the inmate been provided written information that details the expected benefits of the medication, any potential side effects and risks to the inmate from the medication? (Penal Code 2603 (7)(A)
The written information was provided by:

Other
Date the written information was provided:
In my opinion the benefits of the recommended medications outweigh the potential risks:
Treatment alternatives to involuntary medication are unlikely to meet the needs of the patient: (Penal Code 2603 (c)(3))
Treatment alternatives that were considered:

Other
The inmate has been advised of the risks and benefits of, and treatment alternatives to the psychiatric medication: (Penal Code 2603 (c)(4))
Lab tests to rule out medical conditions that may be causing current symptoms:

Other
Name of recommended backup involuntary medication (only if inmate refuses oral medication):
Transfer to LPS Mental Health Facility Attempt

Penal Code 2306 (c)(5)
The jail has made a documented attempt to locate an available bed for the inmate in a community-based treatment facility in lieu of seeking to administer involuntary medication. (Penal Code 2306 (c)(5))
Local facilities contacted for possible transfer:

Other
Reason provided for denial of patient transfer

Other
Emergency or Interim Medication administration

Penal Code 2603 (d)
Does the patient need to be treated with medications on an emergency or interim basis and are you requesting an EX PARTE order?
Has the patient already required treatment with emergency medications?
Please provide the reason and cirumstances surrounding the administration of emergency medications:

Other
List the name(s) of the emergency medication(s) and the dates that they were administered:
Have medications already begun to be administered in an interim basis?
I attest that an urgent situation exists and there has been a sudden and marked change in an inmate's mental condition and that action is immediately necessary for the preservation of life or the prevention of serious bodily harm to the inmate or others, and it is impractical, due to the seriousness of the emergency, to first obtain informed consent.
Only the medication that is required to treat the emergency condition is being administered and shall be administered for only so long as the emergency continues to exist.
Medication you would like to administer in an emergency or interim basis:
Are you requesting an ex parte order to continue involuntary medications for beyond 72hrs, pending a full hearing?
Date you began or intend to begin administering Involuntary Medications:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
I declare under the penalty of perjury under the laws of the State of California that the foregoing is true and correct as to my own personal knowledge unless otherwise stated, and if called upon as a witness in a Court of Law, I could and would testify competently thereto.
Psychiatrist Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which Psychiatrist will be completing the second evaluation?
2nd Psychiatrist Evaluation and Certification
Psychiatrist #2 Name:
Date of 2nd opinion evaluation:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have independently evaluated the above-named inmate and reviewed the information provided by the primary Psychiatrist above:

Other
The inmate is currently being administered emergency or interim medications at the discretion of the primary psychiatrist:
The primary psychiatrist is requesting an ex parte order to continue involuntary medications for beyond 72hrs, pending a full hearing:
Additional information from Psychiatrist #2
I declare under the penalty of perjury under the laws of the State of California that the foregoing is true and correct as to my own personal knowledge unless otherwise stated, and if called upon as a witness in a Court of Law, I could and would testify competently thereto.
Signature of Psychiatrist #2
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Email of 2nd Psychiatrist
  example@example.com
- Should be Empty:

Involuntary Medication Request Form

Primary Psychiatrist Evaluation:

Transfer to LPS Mental Health Facility Attempt

Emergency or Interim Medication administration

2nd Psychiatrist Evaluation and Certification