Fillable Printable Declaration for Mental Health Treatment

Declaration for Mental Health Treatment

DDeclaration for Mental Health Treatmentd

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 2 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 treatment,

treatment of mental illness with psychotropic medication, and admission to and retention in a health care facility for a

period up to 17 days.

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:

_______ I consent to the administration of the following medications:

________________________________________________________________________________________________

_______ I do not consent to the administration of the following 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:

_______ I consent to the administration of electroconvulsive treatment.

_______ I do not consent to the administration of electroconvulsive treatment.

Conditions or limitations: ___________________________________________________________________________

________________________________________________________________________________________________

(continued)

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:

_______ I consent to being admitted to a health care facility for mental health treatment.

_______ I do not 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.

Conditions or limitations: ___________________________________________________________________________

________________________________________________________________________________________________

SELECTION OF PHYSICIAN (optional)

If it becomes necessary to determine if I have become incapable of giving or withholding informed consent for mental

health treatment, I choose Dr. ______________________________ of ______________________________ to be one of

the 2 physicians who will determine whether I am incapable. If that physician is unavailable, that physician’s designee

shall determine whether I am incapable.

ADDITIONAL REFERENCES OR INSTRUCTIONS

________________________________________________________________________________________

Conditions or limitations: ___________________________________________________________________

________________________________________________________________________________________

ATTORNEY-IN-FACT

I hereby appoint:

NAME___________________________________________________________________________________________

ADDRESS _______________________________________________________________________________________

TELEPHONE# ____________________________________________________________________________________

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.

(continued)

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ATTORNEY-IN-FACT (continued)

If the person named above 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# ____________________________________________________________________________________

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 may [sic] 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.

________________________________________________________________________________________

(Signature of Principal/Date)

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.

Witnessed By:

____________________________________________ ____________________________________________

(Signature of Witness/Date) (Printed Name of Witness)

____________________________________________ ____________________________________________

(Signature of Witness/Date) (Printed Name of Witness)

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 appoint-

ment. 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 2 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 of Witness)

____________________________________________ ____________________________________________

(Signature of Attorney-in-fact/Date) (Printed Name of Witness)

(continued)

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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 3 types of mental health treatment: psychotropic medica-

tion, 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 2 physicians or the court 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 inca-

pable. 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 document will continue in effect for a period of 3 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. The revocation may be in a

form similar to the following:

REVOCATION

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

________________________________________________________________________________________________

Date__________________ Signed _____________________________________________________________

(Signature of principal)

I, Dr. _____________________________, have evaluated the principal and determined that he or she is capable of giving

or withholding informed consent for mental health treatment.

Date__________________ Signed _____________________________________________________________

(Signature of physician)

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. This

declaration will not be valid unless it is signed by 2 qualified witnesses who are personally known to you and who are

present when you sign or acknowledge your signature.

History

(Source: P.A. 89-439, § 75.)