Sonoma — Medication Recommendation

Source: https://sonoma.courts.ca.gov/system/files/forms-and-filings/mhd-medication-recommendation-form.pdf

Sonoma County Superior Court Mental Health Diversion Court Medication Recommendation

Name and Contact Information

Name of Patient

Name of Treatment Provider

Title of Treatment Provider Agency of Treatment Provider Address of Treatment Provider Phone Number of Treatment Provider

My name is ____________________________. I am the treatment provider for _________________________________.

This patient has been diagnosed with the following mental health conditions:

---

---

---

To successfully manage this patient’s diagnosis, I recommend the following medication(s), and the patient has agreed to this course of treatment:

---

---

---

To successfully manage this patient’s diagnosis, I recommend the following medication(s), but the patient will not agree to this course of treatment:

---

---

---

I am not endorsing THC for medicinal or recreational use. Generally speaking, THC IS contraindicated for use

with the diagnosis and medication listed above.

I am not endorsing THC for medicinal or recreational use. Generally speaking, THC IS NOT contraindicated for

use with the diagnosis and medication listed above.

Comments:

---

---

---

SIGN

Signed: _____________________________________________________________________________

Print Name and Title: _____________________________________________ Date: ______________

Forms MUST be emailed to MHDreports@sonomacourt.org Revised 11/27/24