Declaration for Mental Health Treatment I_______________________________________________, born on__________, 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 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) American LegalNet, Inc. www.FormsWorkFlow.com Declaration for Mental Health Treatment ADMISSION TO AND RETENTION IN FACILITY Page 2 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 two 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) American LegalNet, Inc. www.FormsWorkFlow.com Declaration for Mental Health Treatment ATTORNEY-IN-FACT (continued) Page 3 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 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. ______________________________________________________________________________ (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 Wi