HUMAN RIGHTS COMMITTEE

HUMAN RIGHTS COMMITTEE
Consumer Name*
First NameLast Name
Date of Behavior Support Plan and/or Medication Reduction Plan*
MonthDayYear
Date
Reason for Review*
Initial Behavior Support PlanUpdated Behavior Support PlanMedication Reduction PlanMedication ChangeOther
If other, give details
Brief Description of Restrictions for Review*
Psychotropic Medication, Diagnosis, Side Effects:
Medication Name:   1
Dosage:   2
Prescriber Name:   3
Reason for Medication is being Prescribed (Diagnosis or specific behavior(s):   4
Possible Side Effects:
Possible Side Effects:
Medication Name:   5
Dosage:   6
Prescriber Name:   7
Reason for Medication is being Prescribed (Diagnosis or specific behavior(s):   8
Possible Side Effects:
Medication Name:   9
Dosage:   10
Prescriber Name:   11
Reason for Medication is being Prescribed (Diagnosis or specific behavior(s):   12
Possible Side Effects:
Medication Name:   13
Dosage:   14
Prescriber Name:   15
Reason for Medication is being Prescribed (Diagnosis or specific behavior(s):   16
Possible Side Effects:
Medication Name:   17
Dosage:   18
Prescriber Name:   19
Reason for Medication is being Prescribed (Diagnosis or specific behavior(s):   20
Possible Side Effects:
If PRN is prescribed, include the Prescriber's criteria for when the PRN is to be administered:
BC Presenting:
Clear
BC Printed Name:*
First NameLast Name
Date Submitted:*
MonthDayYear
Date
Should be Empty:

Psychotropic Medication, Diagnosis, Side Effects: