STATE OF NORTH CAROLINA ADVANCE INSTRUCTION FOR MENTAL HEALTH TREATMENT COUNTY OF (NOTICE TO PERSON MAKING AN INSTRUCTION FOR MENTAL HEALTH TREATMENT This is an important legal document. It creates an instruction for mental health treatment. Before signing this document you should know these important facts: This document allows you to make decisions in advance about certain types of mental health treatment. The instructions you include in this declaration will be followed if a physician or eligible psychologist determines that you are incapable of making and communicating treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments. Your instructions may be overridden if you are being held in accordance with civil commitment law. Under the Health Care Power of Attorney you may also appoint a person as your health care agent to make treatment decisions for you if you become incapable. You have the right to revoke this document at any time you have not been determined to be incapable. YOU MAY NOT REVOKE THIS ADVANCE INSTRUCTION WHEN YOU ARE FOUND INCAPABLE BY A PHYSICIAN OR OTHER AUTHORIZED MENTAL HEALTH TREATMENT PROVIDER. A revocation is effective when it is communicated to your attending physician or other provider. The physician or other provider shall note the revocation in your medical record. To be valid, this advance instruction must be signed by two qualified witnesses, personally known to you, who are present when you sign or acknowledge your signature. It must also be acknowledged before a notary public. NOTICE TO PHYSICIAN OR OTHER MENTAL HEALTH TREATMENT PROVIDER Under North Carolina law, a person may use this advance instruction to provide consent for future mental health treatment if the person later becomes incapable of making those decisions. Under the Health Care Power of Attorney the person may also appoint a health care agent to make mental health treatment decisions for the person when incapable. A person is incapable when in the opinion of a physician or eligible psychologist the person currently lacks sufficient understanding or capacity to make and communicate mental health treatment decisions. This document becomes effective upon its proper execution and remains valid unless revoked. Upon Page 1 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 2 being presented with this advance instruction, the physician or other provider must make it a part of the persons medical record. The attending physician or other mental health treatment provider must act in accordance with the statements expressed in the advance instruction when the person is determined to be incapable, unless compliance is not consistent with G.S. 122C- 74(g). The physician or other mental health treatment provider shall promptly notify the principal and, if applicable, the health care agent, and document noncompliance with any part of an advance instruction in the principals medical record. The physician or other mental health treatment provider may rely upon the authority of a signed, witnessed, dated and notarized advance instruction, as provided in G.S. 122C-75.) I, , being an adult of sound mind, willfully and voluntarily make this advance instruction for mental health treatment to be followed it if is determined by a physician or eligible psychologist 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 the process of providing for the physical, emotional, psychological, and social needs of the principal. Mental health treatment includes electroconvulsive treatment (ECT), commonly referred to as shock treatment, treatment of mental illness with psychotropic medication, and admission to and retention in a facility for care or treatment of mental illness. I understand that under G.S. 122C-57, other than for specific exceptions stated there, mental health treatment may not be administered without my express and informed written consent or, if I am incapable of giving my informed consent, the express and informed consent of my legally responsible person, my health care agent named pursuant to a valid health care power of attorney, or my consent expressed in this advance instruction for mental health treatment. I understand that I may become incapable of giving or withholding informed consent for mental treatment due to the symptoms of a diagnosed mental disorder. These symptoms may include: . Page 2 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 3 PSYCHOACTIVE MEDICATIONS If I become incapable of giving or withholding informed consent for mental health treatment, my instructions regarding psychoactive medications are as follo(ws: Place initials beside choice. ) ______ I consent to the administration of the following medications: ______ I do not consent to the administration of the following medications: Conditions or limitations: ADMISSION TO AND RETENTION IN FACILITY If I become incapable of giving or withholding informed consent for mental health treatment, my instructions regarding admission to and retention in a health care facility for mental health treatment are as follows: (Place initials beside choice.) _____ I consent to being admitted to a health care facility for mental health treatment. My facility preference is . _____ I do not consent to being admitted to a health care facility for mental health treatment. This advance instruction cannot, by law, provide consent to retain me in a facility for more than ten (10) days. Conditions or limitations: ADDITIONAL INSTRUCTIONS These instructions shall apply during the entire length of my incapacity. In case of mental health crisis, please contact: 1. Name: Home Address: Home Telephone Number: Work Telephone Number: Relationship to Me: Page 3 of 7 American LegalNet, Inc. www.USCourtForms.com>>>> 4 2. Name: Home Address: Home Telephone Number: Work Telephone Number: Relationship to Me: 3. My Physician: Name: Telephone Number: 4. My Therapist: Name: Telephone Number: The following may cause me to experience a mental health crisis: The following help me avoid a hospitalization: I generally react to being hospitalized as follows: Staff of the hospital or crisis unit can help me by doing the following: I give permission for