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Fax:
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Website: www.NAMIGC.ORG
The
NAMI of
Greater
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.
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 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 mental
health 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)