62A-15-1004 - Declaration for mental health treatment -- Form.
62A-15-1004. Declaration for mental health treatment -- Form.
A declaration for mental health treatment shall be in substantially the following form:
I, ________________________________, being an adult of sound mind, willfully andvoluntarily make this declaration for mental health treatment, to be followed if it is determinedby a court or by two physicians that my ability to receive and evaluate information effectively orto communicate my decisions is impaired to such an extent that I lack the capacity to refuse orconsent to mental health treatment. "Mental health treatment" means convulsive treatment,treatment with psychoactive medication, and admission to and retention in a mental healthfacility for a period up to 17 days.
I understand that I may become incapable of giving or withholding informed consent formental health treatment due to the symptoms of a diagnosed mental disorder. These symptomsmay include:
______________________________________________________________________________
______________________________________________________________________________If I become incapable of giving or withholding informed consent for mental healthtreatment, my wishes regarding psychoactive medications are as follows:
__________ I consent to the administration of the following medications:
______________________________________________________________________________
in the dosages:
__________ considered appropriate by my attending physician.
__________ approved by ________________________________________
__________ as I hereby direct: ____________________________________
__________ I do not consent to the administration of the following medications:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If I become incapable of giving or withholding informed consent for mental healthtreatment, my wishes regarding convulsive treatment are as follows:
__________ I consent to the administration of convulsive treatment of the following type:
______________________________________________, the number of treatments to be:
__________ determined by my attending physician.
__________ approved by _______________________________________
__________ as follows: ________________________________________
__________ I do not consent to the administration of convulsive treatment.
My reasons for consenting to or refusing convulsive treatment are as follows;
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If I become incapable of giving or withholding informed consent for mental healthtreatment, my wishes regarding admission to and retention in a mental health facility are asfollows:
__________ I consent to being admitted to the following mental health facilities:
____________________________________________________________________________
I may be retained in the facility for a period of time:
__________ determined by my attending physician.
__________ approved by _______________________________________
__________ no longer than _____________________________________
This directive cannot, by law, provide consent to retain me in a facility for more than 17 days.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I hereby appoint:
NAME ________________________________________________
ADDRESS _____________________________________________
TELEPHONE # _________________________________________
to act as my attorney-in-fact to make decisions regarding my mental health treatment if I becomeincapable of giving or withholding informed consent for that treatment.
If the person named above refuses or is unable to act on my behalf, or if I revoke thatperson's authority to act as my attorney-in-fact, I authorize the following person to act as myalternative attorney-in-fact:
NAME ________________________________________________
ADDRESS _____________________________________________
TELEPHONE # _________________________________________
My attorney-in-fact is authorized to make decisions which are consistent with the wishesI have expressed in this declaration. If my wishes are not expressed, my attorney-in-fact is to actin good faith according to what he or she believes to be in my best interest.
_________________________________________
(Signature of Declarant/Date)
We affirm that the declarant is personally known to us, that the declarant signed oracknowledged the declarant's signature on this declaration for mental health treatment in ourpresence, that the declarant appears to be of sound mind and does not appear to be under duress,fraud, or undue influence. Neither of us is the person appointed as attorney-in-fact by thisdocument, the attending physician, an employee of the attending physician, an employee of theDivision of Substance Abuse and Mental Health within the Department of Human Services, anemployee of a local mental health authority, or an employee of any organization that contractswith a local mental health authority.
Witnessed By:
_____________________________________ ______________________________________
(Signature of Witness/Date) (Printed Name of Witness)
_____________________________________ _______________________________________
(Signature of Witness/Date) (Printed Name of Witness)
I accept this appointment and agree to serve as attorney-in-fact to make decisions about
mental health treatment for the declarant. I understand that I have a duty to act consistently withthe desires of the declarant as expressed in the declaration. I understand that this document givesme authority to make decisions about mental health treatment only while the declarant isincapable as determined by a court or two physicians. I understand that the declarant may revokethis appointment, or the declaration, in whole or in part, at any time and in any manner, when thedeclarant is not incapable.
____________________________________ _______________________________________
(Signature of Attorney-in-fact/Date) (Printed name)
____________________________________ ________________________________________
(Signature of Alternate Attorney-in-fact/Date) (Printed name)
This is an important legal document. It is a declaration that allows, or disallows, mentalhealth treatment. Before signing this document, you should know that:
(1) this document allows you to make decisions in advance about three types of mentalhealth treatment: psychoactive medication, convulsive therapy, and short-term (up to 17 days)admission to a mental health facility;
(2) the instructions that you include in this declaration will be followed only if a court ortwo physicians believe that you are incapable of otherwise making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for treatment;
(3) you may also appoint a person as your attorney-in-fact to make these treatmentdecisions for you if you become incapable. The person you appoint has a duty to act consistentlywith your desires as stated in this document or, if not stated, to make decisions in accordancewith what that person believes, in good faith, to be in your best interest. For the appointment tobe effective, the person you appoint must accept the appointment in writing. The person also hasthe right to withdraw from acting as your attorney-in-fact at any time;
(4) this document will continue in effect for a period of three years unless you becomeincapable of participating in mental health treatment decisions. If this occurs, the directive willcontinue in effect until you are no longer incapable;
(5) you have the right to revoke this document in whole or in part, or the appointment ofan attorney-in-fact, at any time you have not been determined to be incapable. YOU MAY NOTREVOKE THE DECLARATION OR APPOINTMENT WHEN YOU ARE CONSIDEREDINCAPABLE BY A COURT OR TWO PHYSICIANS. A revocation is effective when it iscommunicated to your attending physician or other provider; and
(6) if there is anything in this document that you do not understand, you should ask anattorney to explain it to you. This declaration is not valid unless it is signed by two qualifiedwitnesses who are personally known to you and who are present when you sign or acknowledgeyour signature.
Renumbered and Amended by Chapter 8, 2002 Special Session 5