DECLARATION FOR MENTAL HEALTH TREATMENT
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 a court that my ability to understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment is impaired to such an extent that I lack the capacity to make mental health treatment decisions. "Mental health treatment" means electro convulsive or other convulsive treatment, treatment of mental illness with psychoactive medication, or preferences regarding emergency mental health treatment.
(OPTIONAL:) 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:____________________________________________________________________
PSYCHOACTIVE MEDICATIONS If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychoactive medications are as follows:
__________________________________________________________________________
I consent to the administration of the following medications:
__________________________________________________________________________
I do not consent to the administration of the following medications: __________________________________________________________________________
I do consent to the administration of a Federal Drug Administration approved medication that was only approved and in existence after my declaration and that is considered in the same class of psychoactive medications as stated below: __________________________________________________________________________________=
__________________________________________________________________________________
Conditions or limitations:_________________________________________________________________________
__________________________________________________________________________________
CONVULSIVE TREATMENT If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding convulsive treatment are as follows:
____ I consent to the administration of convulsive treatment.
____ I do not consent to the administration of convulsive treatment: Conditions or limitations: ______________________________________________________________
PREFERENCES FOR EMERGENCY TREATMENT
In an emergency, I prefer the following treatment
FIRST: (circle one) Restraint/Seclusion/Medication
In an emergency, I prefer the following treatment
SECOND: (circle one) Restraint/Seclusion/Medication
In an emergency, I prefer the following treatment
THIRD: (circle one) Restraint/Seclusion/Medication
_______ I prefer a male/female to administration restraint, seclusion and/or medications.
Options for treatment prior to use of restraint, seclusion and or medications.________________________________________________________________________ Conditions or 1imitations_________________________________________________________________________
ADDITIONAL REFERENCES OR INSTRUCTIONS
_________________________________________________________________________________
Conditions or 1imitions___________________________________________________________________________
SIGNATURE OF PRINCIPAL:__________________________________________ DATE:_____________________________________________
STATEMENT OF WITNESSES I declare under penalty of perjury that the principal's name has been represented to me by the principal that the principal signed or acknowledged this declaration in my presence, that I believe the principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of the document and is signing it voluntarily and free from duress, that the principal requested that I serve a witness to the principal's execution of this document, and that I am not a provider of health or residential care to the principal, an employee of a provider of health or residential care to the principal an operator of a community health care facility providing care to the principal, or an employee of an operator of a community health care facility providing care to the principal. I declare that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge I am not entitled to and do not have a claim against any part of the estate of the principal on the death of the principal under a will or by operation of law.
Witness Signature:______________________________________________________
Print Name:_____________________________________________________________ Date:___________________________________________________________________ Address:________________________________________________________________
Witness Signature:______________________________________________________
Print Name:_____________________________________________________________ Date:___________________________________________________________________ Address:________________________________________________________________
II DECLARATION FOR MENTAL HEALTH TREATMENT
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 a court that my ability to understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment is impaired to such an extent that I lack the capacity to make mental health treatment decisions. "Mental health treatment" means electro convulsive or other convulsive treatment, treatment of mental illness with psychoactive medication, or preferences regarding emergency mental health treatment.
(OPTIONAL:) 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:_________________________________________________________________________________
PSYCHOACTIVE MEDICATIONS If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychoactive medications are as follows:
____________ I consent to the administration of the following medications:
____________________________________________________________ ____________
I do not consent to the administration of the following medications: __________________________________________________________________________
I do consent to the administration of a Federal Drug Administration approved medication that was only approved and in existence after my declaration and that is considered in the same class of psychoactive medications as stated below: ______________________________________________________________________________________
Conditions or limitations:______________________________________________________________________________
CONVULSIVE TREATMENT
If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding convulsive treatment are as follows:
____ I consent to the administration of convulsive treatment.
____ I do not consent to the administration of convulsive treatment:
Conditions or limitations: ______________________________________________________________
PREFERENCES FOR EMERGENCY TREATMENT
In an emergency, I prefer the following treatment
FIRST: (circle one) Restraint/Seclusion/Medication
In an emergency, I prefer the following treatment
SECOND: (circle one) Restraint/Seclusion/Medication
In an emergency, I prefer the following treatment
THIRD: (circle one) Restraint/Seclusion/Medication
_______ I prefer a male/female to administration restraint, seclusion and/or medications.
Options for treatment prior to use of restraint, seclusion and or medications._____________________________________________________________
Conditions or 1imitations____________________________________________________
ADDITIONAL REFERENCES OR INSTRUCTIONS
_____________________________________________________________________
Conditions or 1imitions_______________________________________________________
SIGNATURE OF PRINCIPAL:__________________________________________ DATE:_____________________________________________
STATEMENT OF WITNESSES
I declare under penalty of perjury that the principal's name has been represented to me by the principal that the principal signed or acknowledged this declaration in my presence, that I believe the principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of the document and is signing it voluntarily and free from duress, that the principal requested that I serve a witness to the principal's execution of this document, and that I am not a provider of health or residential care to the principal, an employee of a provider of health or residential care to the principal an operator of a community health care facility providing care to the principal, or an employee of an operator of a community health care facility providing care to the principal. I declare that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge I am not entitled to and do not have a claim against any part of the estate of the principal on the death of the principal under a will or by operation of law.
Witness Signature:______________________________________________________
Print Name:_____________________________________________________________ Date:___________________________________________________________________ Address:________________________________________________________________
Witness Signature:______________________________________________________
Print Name:_____________________________________________________________ Date:___________________________________________________________________ Address:________________________________________________________________
