NOTICE
TO PERSON MAKING
A DECLARATION FOR MENTAL HEALTH TREATMENT
This is an important legal document. It
creates a declaration for mental health treatment. Before signing this
document, you should know these important facts:
This document allows you to make decisions in
advance about three types of mental health treatment: psychotropic medication,
electroconvulsive therapy, and short term (up to 17 days) admission to a
treatment facility. The instructions that you include in this declaration will
be followed only if two physicians or a judge believes that you are incapable
of making treatment decisions. Otherwise, you will be considered capable to
give or withhold consent for the treatments.
You may also appoint a person as your
attorney in fact to make these treatment decisions for you if you
become incapable. The person you appoint has a duty to act consistent with your
desires as stated in this document or, if your desires are not stated or
otherwise made known to the attorney in fact, to act in a manner
consistent with what the person in good faith believes to be in your best
interest. For the appointment to be effective, the person you appoint must
accept the appointment in writing. The person also has the right to withdraw
from acting as your attorney in fact at any time.
This declaration will not be valid unless it
is signed by you and by two qualified witnesses who are personally known to you
and who are present when you sign or acknowledge your signature.
This document will continue in effect for a
period of three years unless you become incapable of participating in mental
health treatment decisions. If this occurs, the directive will continue in
effect until you are no longer incapable.
You have the right to revoke this document in
whole or in part at any time you have been determined by a physician to be
capable of giving or withholding informed consent for mental health treatment.
A revocation is effective when it is communicated to your attending physician
in writing and is signed by you and a physician.
If there is anything
in this document that you do not understand, you should ask a lawyer to explain
it to you.
I,
_________________________________________, being an adult of sound mind,
willfully and voluntarily make this declaration for mental health treatment to
be followed if it is determined by two physicians or the court that my ability
to receive and evaluate information effectively or communicate decisions is
impaired to such an extent that I lack the capacity to refuse or consent to
mental health treatment. "Mental health treatment" means
electroconvulsive therapy, psychotropic medication, and admission to and
retention in a health care facility for up to 17 days for treatment of a mental
illness
I understand that I may become incapable of
giving or withholding informed consent for mental health treatment due to the
symptoms of a diagnosed mental disorder. These symptoms may include:
______________________________________________________________________________
______________________________________________________________________________
PSYCHOTROPIC MEDICATIONS
If I
become incapable of giving or withholding informed consent for mental health
treatment, my wishes regarding psychotropic medications are as follows (check
the option that applies):
_____ I consent to the administration of
psychotropic medications.
_____ I consent to the administration of
psychotropic medications except the following:
__________________________________________________________________
_____ I consent to the administration of only
the following psychotropic medications:
__________________________________________________________________
_____ I do not consent to the administration
of any psychotropic medications.
Conditions or limitations:
__________________________________________________
_____________________________________________________________________________
ELECTROCONVULSIVE TREATMENT
If I
become incapable of giving or withholding informed consent for mental health
treatment, my wishes regarding electroconvulsive treatment are as follows
(check the option that applies):
_____ I consent to the administration of
electroconvulsive treatment.
_____ I do not consent to the administration
of electroconvulsive treatment.
Conditions or limitations:
__________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ADMISSION TO AND RETENTION IN FACILITY
If I become incapable of giving or withholding
informed consent for mental health treatment, my wishes regarding admission to
and retention in a health care facility for mental health treatment are as
follows (check the option that applies):
_____ I consent to
being admitted to a health care facility for mental health treatment. (This directive cannot, by law, provide
consent to retain me in a facility for more than 17 days.)
_____ I do not consent
to being admitted to a health care facility for mental health treatment.
Conditions or
limitations:___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
APPOINTMENT OF ATTORNEY IN FACT
I appoint the person
named below to act as my attorney in fact to make decisions
regarding my mental health treatment if I become incapable of giving or
withholding informed consent for that treatment. My attorney in fact is authorized to make decisions
that are consistent with the wishes I have expressed in this declaration or, if
not expressed, as are otherwise known to my attorney in fact. If my
wishes are not expressed and are not otherwise known by my attorney in fact,
my attorney in fact is to act in what he or she believes to be my
best interest.
Name __________________________________________________________________
Address __________________________________________________________________
__________________________________________________________________
Telephone __________________________________________________________________
If this person refuses
or is unable to act on my behalf, or if I revoke that person's authority to act
as my attorney in fact, I authorize the following person to act as
my attorney in fact:
Name __________________________________________________________________
Address __________________________________________________________________
__________________________________________________________________
Telephone __________________________________________________________________
ACCEPTANCE OF APPOINTMENT AS ATTORNEY IN FACT
I accept this
appointment and agree to serve as attorney in fact to make
decisions about mental health treatment for the principal. I understand that I
have a duty to act consistent with the desires of the principal as expressed in
this appointment. I understand that this document gives me authority to make
decisions about mental health treatment only while the principal is incapable
as determined by a court or two physicians. I understand that the principal may
revoke this declaration in whole or in part at any time and in any manner when
the principal is not incapable.
________________________________________ _________________________________
(Signature of Attorney in fact/Date) (Printed Name)
________________________________________ _________________________________
(Signature of Alternate Attorney in fact/Date) (Printed Name)
SELECTION OF PHYSICIAN
If it becomes
necessary to determine if I have become incapable of giving or withholding
informed consent for mental health treatment, I choose the doctor named below
to be one of the two physicians who will determine whether I am incapable. If
that physician is unavailable, that physician's designee shall determine
whether I am incapable.
Name __________________________________________________________________
Address __________________________________________________________________
__________________________________________________________________
Telephone __________________________________________________________________
ADDITIONAL INSTRUCTIONS OR CONDITIONS
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________ ______________________________
(Signature of Principal/Date) (Printed
Name of Principal)
AFFIRMATION OF WITNESSES
We affirm that the
principal is personally known to us, that the principal signed or acknowledged
the principal's signature on this declaration for mental health treatment in
our presence, that the principal appears to be of sound mind and not under
duress, fraud or undue influence, that neither of us is a person appointed as an attorney in fact by
this document; the principal's attending physician or mental health service
provider or a relative of the physician or provider; the owner, operator, or
relative of an owner or operator of a facility in which the principal is a
patient or resident; or a person related to the principal by blood, marriage or
adoption.
_________________________________________ ______________________________
(Signature of Witness/Date) (Printed
Name of Witness)
_________________________________________ ______________________________
(Signature of Witness/Date) (Printed
Name of Witness)
REVOCATION
I understand that I have the right to revoke
this document in whole or in part at any time that I have been determined by a
physician to be capable of giving or withholding informed consent for mental
health treatment. A revocation is effective when it is communicated to my
attending physician in writing and is signed by both a physician and me.
I, _______________________________________,
willfully and voluntarily revoke my declaration for mental health treatment as
indicated:
_____ I revoke my entire declaration.
_____ I revoke the
following portion of my declaration:
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
(Signature of Principal/Date)
I, the undersigned
physician, have evaluated the principal and determined that he or she is
capable of giving or withholding informed consent for mental health treatment.
__________________________________________ ______________________________
(Signature of Physician/Date) (Printed
name)