Attestation of Licensed Medical Provider (LMP) Consultation

Client Name: Name of Client

Instructions: Prior to a conditional release hearing, administrative hearing, or any other permanent change in LMP (i.e., the practitioner prescribing medication to the client), the prospective LMP must engage in a consultation with the current LMP. Following this consultation, the prospective LMP completes this form and submits it to the PSRB.

Date of Hearing: Date	Anticipated Date of Transition: Date
Current Treating LMP: Name, Credential	Proposed LMP: Name, Credential
Current LMP’s DSM V-TR Diagnosis(es): Click or tap here to enter text.	Current Psychotropic Medication: Click or tap here to enter text.

Attestations of LMP Consultation:

On Date, an LMP consultation took place with Name, Credential, the client’s current LMP.

The proposed community placement is familiar with the relationship between the client’s risk factors and potentially dangerous behaviors.	Yes ☐	No ☐

The proposed community placement is familiar with the client’s medication history and current medication regimen.	Yes ☐	No ☐

Are there any additional planned medication changes? If yes, please describe:

Yes ☐	No ☐

Click or tap here to enter text.

Additional comments/ concerns discussed during consultation relevant to conditional release:

Click or tap here to enter text.

This form is due either 10 days prior to a scheduled full or administrative hearing or within 14 days of an emergency placement.

Enter “N/A” if this form is being completed solely to record a change in LMP.