§ 122C-77. Statutory form for advance instruction for mental health treatment.
§122C‑77. Statutory form for advance instruction for mental healthtreatment.
(a) This Part shall notbe construed to invalidate an advance instruction for mental health treatmentthat was executed prior to January 1, 1999, and was otherwise valid.
(b) The use of thefollowing or similar form after the effective date of this Part in the creationof an advance instruction for mental health treatment is lawful, and, whenused, it shall specifically meet the requirements and be construed inaccordance with the provisions of this Part.
"ADVANCE INSTRUCTION FOR MENTAL HEALTH TREATMENT
I, ___________________________,being an adult of sound mind, willfully and voluntarily make this advanceinstruction for mental health treatment to be followed if it is determined by aphysician or eligible psychologist that my ability to receive and evaluateinformation effectively or communicate decisions is impaired to such an extentthat I lack the capacity to refuse or consent to mental health treatment."Mental health treatment" means the process of providing for thephysical, emotional, psychological, and social needs of the principal."Mental health treatment" includes electroconvulsive treatment (ECT),commonly referred to as "shock treatment", treatment of mental illnesswith psychotropic medication, and admission to and retention in a facility forcare or treatment of mental illness.
I understand that under G.S. 122C‑57,other than for specific exceptions stated there, mental health treatment maynot be administered without my express and informed written consent or, if I amincapable of giving my informed consent, the express and informed consent of mylegally responsible person, my health care agent named pursuant to a validhealth care power of attorney, or my consent expressed in this advanceinstruction for mental health treatment. I understand that I may becomeincapable of giving or withholding informed consent for mental health treatmentdue to the symptoms of a diagnosed mental disorder. These symptoms may include:
PSYCHOACTIVE MEDICATIONS
If I become incapable of givingor withholding informed consent for mental health treatment, my instructionsregarding psychoactive medications are as follows: (Place initials besidechoice.)
_______ I consent tothe administration of the following medications:
_______ I do notconsent to the administration of the following medications:
______________________________________________________________________________
______________________________________________________________________________
Conditions or limitations:___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ADMISSION TO AND RETENTION IN FACILITY
If I become incapable of givingor withholding informed consent for mental health treatment, my instructionsregarding admission to and retention in a health care facility for mentalhealth treatment are as follows: (Place initials beside choice.)
_______ I consent tobeing admitted to a health care facility for mental health treatment.
My facility preference is____________________________________________________________
_______ I do notconsent to being admitted to a health care facility for mental healthtreatment.
This advance instruction cannot,by law, provide consent to retain me in a facility for more than 10 days.
Conditions or limitations___________________________________________________________
______________________________________________________________________________
ADDITIONAL INSTRUCTIONS
These instructions shall applyduring the entire length of my incapacity.
In case of mental health crisis,please contact:
1. Name:________________________________________________________________
HomeAddress:______________________________________________________
HomeTelephone Number:_____________________________________________
WorkTelephone Number:______________________________________________
Relationshipto Me:___________________________________________________
2. Name:________________________________________________________________
HomeAddress:______________________________________________________
HomeTelephone Number:_____________________________________________
WorkTelephone Number:______________________________________________
Relationshipto Me:___________________________________________________
3. My Physician:
Name:_____________________________________________________________
TelephoneNumber:___________________________________________________
4. My Therapist:
Name:_____________________________________________________________
TelephoneNumber:___________________________________________________
The following may cause me toexperience a mental health crisis:
______________________________________________________________________________
______________________________________________________________________________
The following may help me avoid ahospitalization:________________________________________
______________________________________________________________________________
______________________________________________________________________________
I generally react to beinghospitalized as follows:_________________________________________
______________________________________________________________________________
______________________________________________________________________________
Staff of the hospital or crisisunit can help me by doing the following:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I give permission for thefollowing person or people to visit me:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Instructions concerning any othermedical interventions, such as electroconvulsive (ECT) treatment (commonlyreferred to as "shock treatment"):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other instructions:________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______ I have attachedan additional sheet of instructions to be followed and considered part of thisadvance instruction.
SHARING OF INFORMATION BY PROVIDERS
I understand that the informationin this document may be shared by my mental health treatment provider with anyother mental health treatment provider who may serve me when necessary toprovide treatment in accordance with this advance instruction.
Other instructions about sharingof information:
______________________________________________________________________________
______________________________________________________________________________
SIGNATURE OF PRINCIPAL
By signing here, I indicate thatI am mentally alert and competent, fully informed as to the contents of thisdocument, and understand the full impact of having made this advanceinstruction for mental health treatment.
Signature of Principal Date
NATURE OF WITNESSES
I hereby state that the principalis personally known to me, that the principal signed or acknowledged theprincipal's signature on this advance instruction for mental health treatmentin my presence, that the principal appears to be of sound mind and not underduress, fraud, or undue influence, and that I am not:
a. The attendingphysician or mental health service provider or an employee of the physician ormental health treatment provider;
b. An owner, operator,or employee of an owner or operator of a health care facility in which theprincipal is a patient or resident; or
c. Related within thethird degree to the principal or to the principal's spouse.
AFFIRMATION OF WITNESSES
We affirm that the principal ispersonally known to us, that the principal signed or acknowledged theprincipal's signature on this advance instruction for mental health treatmentin our presence, that the principal appears to be of sound mind and not underduress, fraud, or undue influence, and that neither of us is:
A person appointed as an attorney‑in‑factby this document;
The principal's attendingphysician or mental health service provider or a relative of the physician orprovider;
The owner, operator, or relativeof an owner or operator of a facility in which the principal is a patient orresident; or
A person related to the principalby blood, marriage, or adoption.
Witnessed by:
Witness:_____________________________ Date:________________________________
Witness:_____________________________ Date:________________________________
STATE OF NORTH CAROLINA
COUNTY OF____________________________________
CERTIFICATION OF NOTARY PUBLIC
STATE OF NORTH CAROLINA
COUNTY OF
I, __________________________, aNotary Public for the County cited above in the State of North Carolina, herebycertify that ____________________ appeared before me and swore or affirmed tome and to the witnesses in my presence that this instrument is an advanceinstruction for mental health treatment, and that he/she willingly andvoluntarily made and executed it as his/her free act and deed for the purposesexpressed in it.
I further certify that_____________________and _____________________, witnesses, appeared before meand swore or affirmed that they witnessed _________________________ sign theattached advance instruction for mental health treatment, believing him/her tobe of sound mind; and also swore that at the time they witnessed the signingthey were not (i) the attending physician or mental health treatment provideror an employee of the physician or mental health treatment provider and (ii)they were not an owner, operator, or employee of an owner or operator of ahealth care facility in which the principal is a patient or resident, and (iii)they were not related within the third degree to the principal or to theprincipal's spouse. I further certify that I am satisfied as to the genuinenessand due execution of the instrument.
This isthe ____________ day of___________________________,______________________
__________________________________________
NotaryPublic
My Commission expires:
NOTICE TO PERSON MAKING ANINSTRUCTION FOR MENTAL HEALTH TREATMENT
This is an important legaldocument. It creates an instruction for mental health treatment. Before signingthis document you should know these important facts:
This document allows you to makedecisions in advance about certain types of mental health treatment. Theinstructions you include in this declaration will be followed if a physician oreligible psychologist determines that you are incapable of making andcommunicating treatment decisions. Otherwise you will be considered capable togive or withhold consent for the treatments. Your instructions may beoverridden if you are being held in accordance with civil commitment law. Underthe Health Care Power of Attorney you may also appoint a person as your healthcare agent to make treatment decisions for you if you become incapable. Youhave the right to revoke this document at any time you have not been determinedto be incapable. YOU MAY NOT REVOKE THIS ADVANCE INSTRUCTION WHEN YOU ARE FOUNDINCAPABLE BY A PHYSICIAN OR OTHER AUTHORIZED MENTAL HEALTH TREATMENT PROVIDER.A revocation is effective when it is communicated to your attending physicianor other provider. The physician or other provider shall note the revocation inyour medical record. To be valid, this advance instruction must be signed bytwo qualified witnesses, personally known to you, who are present when you signor acknowledge your signature. It must also be acknowledged before a notarypublic.
NOTICE TO PHYSICIAN OR OTHERMENTAL HEALTH TREATMENT PROVIDER
Under North Carolina law, aperson may use this advance instruction to provide consent for future mentalhealth treatment if the person later becomes incapable of making thosedecisions. Under the Health Care Power of Attorney the person may also appointa health care agent to make mental health treatment decisions for the personwhen incapable. A person is "incapable" when in the opinion of aphysician or eligible psychologist the person currently lacks sufficientunderstanding or capacity to make and communicate mental health treatmentdecisions. This document becomes effective upon its proper execution andremains valid unless revoked. Upon being presented with this advanceinstruction, the physician or other provider must make it a part of theperson's medical record. The attending physician or other mental healthtreatment provider must act in accordance with the statements expressed in theadvance instruction when the person is determined to be incapable, unlesscompliance is not consistent with G.S. 122C‑74(g). The physician or othermental health treatment provider shall promptly notify the principal and, ifapplicable, the health care agent, and document noncompliance with any part ofan advance instruction in the principal's medical record. The physician orother 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.(1997‑442, s. 2; 1998‑198, s. 2; 1998‑217,s. 53(a)(5).)