This memo introduces form CD-275, Informed Consent for Psychotropic Medication. With implementation of the revised informed consent policy in September 2018, there have been regular requests for the development of a form to assist staff when weighing informed consent decisions. This form intends to support staff in gathering relevant information before making an informed decision while also serving as the required authorization and documentation of such decision. The CD-275 will also assist staff conducting required periodic medical reviews of selected case records. 

Effective upon release of this memo, the CD-275 is required to be completed any time a decision is being considered for a new psychotropic medication recommended by the child’s medical provider. Dosage increases and decreases for a medication already approved do not require additional informed consent or completion of this form, nor does the emergency administration of a psychotropic medication ordered by a physician. 

The form is separated into sections, Part A to be completed by the case manager prior to the appointment with the prescriber, and Part B to be completed with the prescriber. A section is provided to document the youth’s assent (for ages 12-17), and a field to document parental notification. Parents/legal guardians – absent a court order restricting their access - and resource parents should be notified of, and encouraged to attend or participate in, all appointments. 

A copy of the completed form must be uploaded through document imaging and maintained in the case file until further notice per Director Memo TD17-09.