For children in Tennessee DCS custody, the prescriber records every psychotropic medication evaluation on this form, or provides their own documentation with the same information. It lists the DSM-5 diagnosis, symptoms, other treatments, each current or discontinued medication with dose, frequency, route and refills, the reasons for changes, vitals, labs and the next appointment.
The prescribing psychiatrist, physician or nurse practitioner completes and signs the form at each medication evaluation appointment. It also records the child's name, DOB, Electronic Record System ID, home county and family service worker (FSW) name, plus the provider and clinic details.
Download the current version from the source each time; forms change without notice.
Psychotropic Medication Evaluation
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The form says to complete it at every medication evaluation appointment for a child in DCS custody. It also notes that healthcare providers may prefer to provide their own documentation covering the same information, such as diagnosis, symptoms, medications and changes.
Mark the medication as new on CS-0629 and attach form CS-0627, Informed Consent for Psychotropic Medication. The form states that the informed consent must be signed and forwarded to the DCS Health unit along with the evaluation.
The Tennessee DCS forms list shows English and Spanish versions of the Psychotropic Medication Evaluation. The English edition is Rev. 3/25, with routing to regional DCS Health Units printed on page 2.