Involuntary Medication Request Form
Precision Psychiatric Services - Penal Code 2603
Patient Name:
Date of Birth
-
Month
-
Day
Year
Date
Current Facility
Please Select
Bob Wiley
Adult Pretrial Facility
South County Detention Center
Unit and Location (ie 2B-101)
Psychiatrist completing evaluation:
Please Select
Mandeep Bagga, MD
Abdolreza Saadabadi, MD
Arul Sangani, MD
Rahi Daneshvar, MD
Gursimran Kehal, DO
Matthew Bryan, DO
Rama Yasaei, MD
Date of Evaluation
-
Month
-
Day
Year
Date
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)).
Agree
Disagree
Diagnosis based on evaluation:
Please Select
Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
Major Depressive Disorder
Brief Psychotic Disorder
Catatonia
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))
Gravely Disabled and does not have the capacity to refuse treatment with psychiatric medications
Danger to Self
Danger to Others
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))
Yes
No
The basis upon which psychiatric medication is recommended: (Penal code 2603 (7)(A)
Name of recommended voluntary oral medication:
Please Select
Risperdal
Zyprexa
Haldol
Abilify
Clozapine
Ativan
The expected benefits of the medication (Penal Code 2603 (7)(A)):
Reduction or elimination of aggressive or agitated behaviors
Reduction or elimination of self injurious thoughts or behaviors
Reduction in disorganized behaviors
Reduction in hallucinations
Improvement in hygiene and self care
Improved food intake
Improvement in clothing utilization
The potential common side effects and risks to the inmate from the medication: (Penal Code 2603 (7)(A))
Sedation
Dizziness
Restlessness
Falls
Involuntary and abnormal movements (potentially irreversible)
reduction in white blood cell count
headache, nausea, upset stomach (transient)
muscle cramps
suicidal thoughts and behaviors
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)
Yes
No
The written information was provided by:
Myself
Nursing staff
Other
Date the written information was provided:
In my opinion the benefits of the recommended medications outweigh the potential risks:
Yes
No
Treatment alternatives to involuntary medication are unlikely to meet the needs of the patient: (Penal Code 2603 (c)(3))
I agree
Disagree
Treatment alternatives that were considered:
No treatment alternatives to medications exist within the facility or local community
ECT
Other
The inmate has been advised of the risks and benefits of, and treatment alternatives to the psychiatric medication: (Penal Code 2603 (c)(4))
and refuses the medications
is unable to consent to the administration of medication
Lab tests to rule out medical conditions that may be causing current symptoms:
were attempted to be drawn but patient refused. Involuntary medication administration still indicated, and we will continue to attempt to get patient to consent to labs.
were attempted to be drawn but patient was too violent and aggressive to allow safe lab draw. Involuntary medications administration still indicated, and we will continue to attempt to get patient to consent to labs.
were obtained and reviewed. Involuntary medication administration still indicated.
Other
Name of recommended backup involuntary medication (only if inmate refuses oral medication):
Please Select
Zyprexa Intramuscular (IM)
Haldol Intramuscular (IM)
Geodon Intramuscular (IM)
Ativan Intramuscular (IM)
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))
Yes
No
Local facilities contacted for possible transfer:
Kaweah Health Mental Health Hospital
Good Samaritan Hospital
Other
Reason provided for denial of patient transfer
No available beds at facilities
Inmate denied due to inability to accomodate inmate acuity
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?
Yes
No
Has the patient already required treatment with emergency medications?
Yes
No
Please provide the reason and cirumstances surrounding the administration of emergency medications:
Patient was engaging in self injurious behaviors
Patient was engaging in assaultive or aggressive behaviors resulting in a situation dangerous to others
Catatonia
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?
Yes
Interim medications have not yet begun to be admininstered as law enforcement assistance will be required. Law enforcement assistance cannot be obtained without IMO petition and court order.
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.
Yes
No
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.
Yes
No
Medication you would like to administer in an emergency or interim basis:
Please Select
Zyprexa Intramuscular (IM)
Haldol Intramuscular (IM)
Geodon Intramuscular (IM)
Ativan Intramuscular (IM)
Are you requesting an ex parte order to continue involuntary medications for beyond 72hrs, pending a full hearing?
Yes: the current situation jeopardizes the inmate's health or well-being as the result of a serious mental illness, and necessitates the continuation of medication
No
Date you began or intend to begin administering Involuntary Medications:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/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.
Yes
No
Psychiatrist Signature
Date
-
Month
-
Day
Year
Date
Which Psychiatrist will be completing the second evaluation?
Please Select
mbagga@gmail.com
asaada@kaweahhealth.org
asangani@kaweahhealth.org
rdanes@kaweahhealth.org
Ryasaei@gmail.com
gkehal@precisionpsych.com
Send to 2nd Psychiatrist for Review and Opinion
2nd Psychiatrist Evaluation and Certification
Psychiatrist #2 Name:
Please Select
Mandeep Bagga, MD
Abdolreza Saadabadi, MD
Arul Sangani, MD
Rahi Daneshvar, MD
Matthew Bryan, DO
Rama Yasaei, MD
Gursimran Kehal, DO
Date of 2nd opinion evaluation:
-
Month
-
Day
Year
Date
I have independently evaluated the above-named inmate and reviewed the information provided by the primary Psychiatrist above:
I agree with the diagnosis and medication recommendation as reported
I agree that the benefits of medication administration outweigh the risks
I do not agree with either the diagnosis or the medication recommendation made above
Other
The inmate is currently being administered emergency or interim medications at the discretion of the primary psychiatrist:
I agree that an emergency 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.
I disagree with the rationale necessary to justify the administration of emergency or interim medications at this time.
The primary psychiatrist is requesting an ex parte order to continue involuntary medications for beyond 72hrs, pending a full hearing:
I agree that the current situation jeopardizes the inmate's health or well-being as the result of a serious mental illness, and necessitates the continuation of medication
I disagree and do not feel an ex parte order is necessary at this time
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.
Yes
No
Signature of Psychiatrist #2
Date
-
Month
-
Day
Year
Date
Submit
Background Data - Do not change
Email of 2nd Psychiatrist
*
example@example.com
Should be Empty: