Medication Consultation
This form will take approximately 10 minutes to complete.
Name of Individual completing the form:
First Name
Last Name
Relationship to the child:
State of Residence:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
What medications is your child currently taking? Please include the name of the medication, dose, and time of day they take each medication as well as how long they have been on each medication. Are these medications being taken as prescribed?
Who is your current medication prescriber(s)? Examples would include psychiatrist, family physician, etc. How often is your child seen by this prescriber for medication review?
List any medications your child has been on in the past and is no longer taking. List the reason for discontinuation and date the medication was discontinued.
What is working well about your child’s current regimen?
Is your child experiencing any negative side effects due to their current medication regimen?
What behavioral or social/emotional challenges does your child have that you would like to see improve?
Does your child take any supplements or non-pharmacological therapies that could impact their medication regimen?
Does your child use any recreational substances such as alcohol, marijuana or other street drugs?
Any additional information you would like to share or questions you have?
Signature
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sumbit
Sumbit
Should be Empty: