Illinois Department of Children & Family Services
DCFS Consent Team / UIC Research Team
Psychotropic Medication Request
Fax Cover Sheet
Date: Total Pages:
To: DCFS Consent Unit/UIC Research Team: Fax (312) 814-7015 (24-hour fax)
Contact Person
Contact Person Affiliation/Position Contact Person Phone Number Extension
Facility Name: (Hospital/Residential Center/DOC/JJ) Fax Number
Facility Address
From: Agency Name
Agency Phone Number Agency Fax: Number
Doctor Doctor Phone Number Doctor Fax: Number
Doctor Address
Region: Northern Central Southern Cook
Notes/Comments:
Consent Hotline – 800-828-2179
After Hours (Child Intake and Recovery Unit) - 866-503-0184
This message is intended only for the use of the individual or entity to which it is addressed, and may contain information
that is privileged, confidential, or exempt from disclosure under applicable law. If the reader of the message is not the
intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is
strictly prohibited. If you have received this message in error, please notify us immediately by telephone and return the
original to us at the address below via U.S. mail. Thank you for your cooperation.
CFS 431-A Cover
Rev 5/2015
