Mental Healthcare Declaration and Power of Attorney - Word & PDF Template Form Pro · US-law
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DECLARATION FOR MENTAL HEALTH TREATMENT AND DURABLE POWER OF ATTORNEY FOR MENTAL HEALTHCARE
State of ________
Executed on ________
PART I. BACKGROUND AND DECLARATION OF PRINCIPAL
§ 1.1 I, ________, residing at ________ (the “Principal”), being eighteen (18) years of age or older and presently having the capacity to make mental health treatment decisions, willfully and voluntarily make this Declaration for Mental Health Treatment and Durable Power of Attorney for Mental Healthcare (this “Document”).
§ 1.2 I understand that “mental healthcare” means any care, treatment, service, or procedure to maintain, diagnose, treat, or otherwise provide for my mental health, including any program of medication and any therapeutic treatment. Electroconvulsive therapy (ECT) may be administered only if I have specifically consented to it in this Document. I will be the subject of laboratory trials, experimental studies, or research only as specifically provided for in this Document. Mental healthcare under this Document does not include psychosurgery or the termination of parental rights.
§ 1.3 I authorize my designated mental healthcare agent to make decisions on my behalf regarding my mental healthcare as set forth herein. Where I have not expressed a specific choice in this Document, I authorize my agent to make the decision that my agent determines I would make if I were competent to do so, and otherwise in my best interest.
§ 1.4 I understand that my incapacity to make mental health treatment decisions will be determined in writing by a physician, psychiatrist, psychologist, or other qualified mental healthcare professional in accordance with applicable state law, and, where required by such law, confirmed by a second qualified professional. Whenever reasonably possible, one such professional will be among my treating professionals.
PART II. DECLARATION FOR MENTAL HEALTH TREATMENT
§ 2.1 When This Declaration Becomes Effective.
This Declaration becomes effective only when I am determined to be incapable of making mental healthcare decisions by a physician, psychologist, or other qualified mental healthcare professional in accordance with applicable state law, and remains in effect only for so long as I am incapable.
§ 2.2 Treatment Preferences.
(a) Choice of treatment facility.
If I require admission to a psychiatric or other mental health treatment facility, and to the extent reasonably possible, I would prefer to be admitted to the following facility:
________
If I require such admission, I do not wish to be committed to the following facility:
________
I understand that if my preferred placement is not available or appropriate, I may be placed in a facility that is not my preference.
(b) Use of medication for psychiatric treatment. My direction concerning the use of psychiatric medications recommended by my treating physician is:
________
(c) Electroconvulsive therapy (ECT). My direction concerning the administration of ECT recommended by my treating physician (consent, refusal, or conditions) is:
________
I understand that ECT may be administered only if I have specifically consented to it in this Document, and that my agent may not consent to ECT on my behalf in the absence of such specific consent.
(d) Participation in experimental studies and drug trials. My direction concerning my participation in experimental studies, laboratory trials, research, and drug trials (consent, refusal, or conditions) is:
________
(e) Additional instructions and preferences. Any additional instructions, preferences, or limitations regarding my mental healthcare:
________
§ 2.3 Revocation.
So long as I have not been determined to be incapable of making mental health decisions, I may revoke this Declaration in whole or in part at any time, either orally or in writing, by any act evidencing a specific intent to revoke.
A revocation is effective upon communication to my attending physician or other mental healthcare provider, by me or by a witness to the revocation, of the intent to revoke. If I revoke a particular instruction, the remaining instructions continue in effect until: (1) I revoke this Document in its entirety; (2) I execute a new combined declaration and power of attorney for mental healthcare; or (3) this Document otherwise terminates under its terms or applicable law.
§ 2.4 Term and Automatic Termination.
Unless a different period is permitted or required by applicable state law, this Declaration automatically terminates upon the earlier of (a) ________ year(s) from the date of execution, or (b) the maximum period permitted by applicable law; provided, however, that if I am incapable of making mental healthcare decisions at the time this Declaration would otherwise expire, it remains in effect until I regain capacity.
Date signed: ________
PART III. DURABLE POWER OF ATTORNEY FOR MENTAL HEALTHCARE
§ 3.1 I, ________, having the capacity to make mental health decisions, authorize my designated mental healthcare agent to make decisions on my behalf regarding my mental healthcare as set forth herein. Where I have not expressed a choice in this Document or in the accompanying Declaration, I authorize my agent to make the decision that my agent determines I would make if I were competent to do so. This power of attorney is durable and is not affected by my subsequent incapacity.
§ 3.2 When Power of Attorney Becomes Effective.
This Power of Attorney becomes effective when I am determined to be incapable of making mental healthcare decisions by a physician, psychologist, or other qualified mental healthcare professional in accordance with applicable state law, and remains effective only while I am incapable.
§ 3.3 Designation of Agent.
I hereby designate and appoint the following person as my mental healthcare agent to make mental healthcare decisions for me as authorized in this Document. This authorization applies only to mental health decisions not otherwise addressed in the accompanying signed Declaration:
Name: ________
Address: ________
Contact Info: ________
Agent’s Acceptance. I hereby accept designation as mental healthcare agent for ________ in the event he or she is found incapable of making mental healthcare decisions. The Principal has discussed his or her wishes regarding mental healthcare decisions with me. If I choose to withdraw while the Principal is competent, I must notify the Principal of my decision; if I choose to withdraw while the Principal is incapable, I must notify the Principal’s physician.
_______________________________________
Signed: ________, Mental Healthcare Agent
Date: ________
§ 3.4 Designation of Alternate Agent.
If my first agent is unavailable, unwilling, or unable to serve, I hereby designate and appoint the following individual as my alternate mental healthcare agent:
Name: ________
Address: ________
Contact Info: ________
Alternate Agent’s Acceptance. I hereby accept designation as alternate mental healthcare agent for ________ in the event he or she is found incapable of making mental healthcare decisions and the first-named agent is unable to serve. The Principal has discussed his or her wishes regarding mental healthcare decisions with me. If I choose to withdraw while the Principal is competent, I must notify the Principal of my decision; if I choose to withdraw while the Principal is incapable, I must notify the Principal’s physician.
_______________________________________
Signed: ________, Alternate Mental Healthcare Agent
Date: ________
§ 3.5 Authority Granted to Mental Healthcare Agent.
§ 3.6 Limitations on Agent’s Authority.
(a) My agent shall make mental healthcare decisions in accordance with the instructions and preferences I have expressed in this Document and in the accompanying Declaration, and shall not make any decision inconsistent with those instructions and preferences.
(b) My agent shall not consent to ECT unless I have specifically consented to such treatment in this Document or the accompanying Declaration.
(c) My agent shall not consent to my participation in experimental studies, laboratory trials, or research unless I have specifically consented to such participation in this Document or the accompanying Declaration.
(d) My agent shall have no authority to consent to psychosurgery, the termination of my parental rights, or any other procedure expressly excluded from the definition of mental healthcare under this Document, or any action prohibited by applicable law.
§ 3.7 Term and Automatic Termination.
Unless a different period is permitted or required by applicable state law, this Power of Attorney automatically terminates upon the earlier of (a) ________ year(s) from the date of execution, or (b) the maximum period permitted by applicable law; provided that if I am incapable of making mental healthcare decisions at the time it would otherwise expire, it remains in effect until I regain capacity.
PART IV. NOMINATION OF GUARDIAN
§ 4.1 If a court determines that a guardian or conservator of my person is to be appointed, I nominate the following person, to the extent permitted by applicable state law:
Name: ________
Address: ________
Contact Info: ________
§ 4.2 I understand that the appointment of a guardian of my person may give such guardian power to revoke, suspend, or terminate this Document to the extent provided by applicable law and court order.
PART V. GOVERNING LAW; SEVERABILITY
§ 5.1 This Document shall be governed by and construed in accordance with the laws of the State of ________, and shall be administered consistent with applicable federal law, including HIPAA.
§ 5.2 If any provision of this Document is held invalid or unenforceable, the remaining provisions shall continue in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to render it enforceable consistent with my intent.
PART VI. NOTICE TO THIRD PARTIES
EXECUTION BY PRINCIPAL
I, ________, the Principal, sign my name to this Document on the date set forth below and, being first duly sworn, declare to the undersigned authority that I sign and execute this instrument as my Declaration and Power of Attorney for mental healthcare; that I sign it willingly, or willingly direct another to sign for me; that I execute it as my free and voluntary act for the purposes expressed herein; and that I am eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence.
Name of Principal: ________
_____________________________
________, Principal
Date: ________
ACKNOWLEDGMENT / NOTARIZATION
State of ________
County of ________
On this ________ day of ________, 20________, before me, the undersigned authority, personally appeared ________, who is personally known to me or who produced satisfactory evidence of identity, and who, being by me duly sworn, acknowledged that he or she executed the foregoing instrument as his or her free act and deed for the purposes therein expressed.
In witness whereof I hereunto set my hand and official seal.
__________________________________________________________________
Notary Public Signature
Printed Name: ________
My commission expires: ________
STATEMENT OF WITNESSES
Each of the undersigned witnesses declares as follows: I am at least eighteen (18) years of age. I declare under penalty of perjury under the laws of the State of ________ that ________ signed, or expressly directed another person to sign on his or her behalf, this Document in my presence. The Principal is personally known to me or provided evidence sufficient to establish his or her identity, signed this Document voluntarily, and appears to be of sound mind and under no duress, fraud, or undue influence.
I further declare that I am not the Principal’s spouse, parent, child, sibling, or otherwise related to the Principal by blood, marriage, or adoption; that I am not designated as the Principal’s mental healthcare agent or alternate agent; that I am not entitled to any portion of the Principal’s estate, by will or operation of law, to the best of my knowledge; that I am not financially responsible for the Principal’s healthcare costs; and that I am not the Principal’s healthcare provider, nor an owner, operator, or employee of a healthcare facility, treatment facility, or nursing home in which the Principal is a patient or resident.
Witness 1:
__________________________________
(Signature)
Date: ________
Print Name: ________
Full Address: ________
Witness 2:
__________________________________
(Signature)
Date: ________
Print Name: ________
Full Address: ________
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