listed in section A, as recommended by his/her licensed health care provider. I understand that I can withdraw this consent for my child to receive medications at any time during his/her treatment.
By signing below, I do not give consent for
to receive the medications
listed in section A, as recommended by his/her licensed health care provider. Reason consent denied:2
Relationship to Child:
Section C – Consent for administration of psychotropic medications (signed by youth age 18 or older):
I have been informed of the recommendation to prescribe medications as part of my treatment. I have been informed of the nature of my condition, the risks and benefits or treatment with the medications, of other forms of treatment, as well as the risks of no treatment.
A new signed consent is required once a year, when a new medication is started and/or when the dosage exceeds the maximum indicated in the dosage range.
Criteria Triggering Further Review
Prescribed four or more concomitant psychotropic medications
Prescribed two or more concomitant anti-depressants.
Prescribed two or more concomitant anti-psychotics.
Prescribed two or more concomitant stimulant medications.
Prescribed two or more concomitant mood stabilizer medications.
Prescribed psychotropic medications in doses above recommended doses
Prescribed psychotropic medication and child is five years or younger.
1 To the physician: In compliance with the MDHS Guidelines for the Use of Psychotropic Medication for Children in State Custody, the above medication combinations should be avoided. These parameters do not necessarily indicate treatment is inappropriate, but for DHS purposes further review is needed. Check the appropriate box if any apply. An explanation must be provided within the rationale section (under the Medications on pg.1), and you may be contacted for follow up.
1To the caseworker: If the Rationale field in section A is completed and one or more of the check boxes are checked, a copy of the completed Psychotropic Medication Consent Form must be faxed to the DHS Health, Education & Youth Unit at 517-335-7789.
2If consent is denied and all other parties agree medication is needed, a court order is necessary for medication to be administered.
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.