Mental Health Advance Directive of (client name)

With Appointment of (agent name) as

Agent for Mental Health Decisions

 

I, (Client name), being a person with capacity, willfully and voluntarily execute this mental health advance directive so that my choices regarding my mental health care will be carried out in circumstances when I am unable to express my instructions and preferences regarding my mental health care.

In order to assist in carrying out my directive I would like my providers and my agent to know the following information:

I have been diagnosed with (client illnesses both mental health and physical diagnoses) for which I take (list medications).

I am also on the following other medications: (list any other medications for other conditions).

The best treatment method for my illness is (give general overview of what works best for client).

I have/do not have a history of substance abuse. My preferences and treatment options around medication management related to substance abuse are:

(You must complete this part for your directive to be valid.)

I intend that this directive become effective (YOU MUST CHOOSE ONLY ONE):

. . . . . . Immediately upon my signing of this directive.

. . . . . . If I become incapacitated.

. . . . . . When the following circumstances, symptoms, or behaviors occur:

I want this directive to (YOU MUST CHOOSE ONLY ONE):

. . . . . . Remain valid and in effect for an indefinite period of time.

. . . . . . Automatically expire . . . . . . years from the date it was created.

I intend that I be able to revoke this directive (YOU MUST CHOOSE ONLY ONE):

. . . . . . Only when I have capacity.

I understand that choosing this option means I may only revoke this directive if I have capacity. I further understand that if I choose this option and become incapacitated while this directive is in effect, I may receive treatment that I specify in this directive, even if I object at the time.

. . . . . . Even if I am incapacitated.

I understand that choosing this option means that I may revoke this directive even if I am incapacitated. I further understand that if I choose this option and revoke this directive while I am incapacitated I may not receive treatment that I specify in this directive, even if I want the treatment.

I would like the physician(s), physician assistant(s), or advanced registered nurse practitioner(s) named below to be involved in my treatment decisions:

I do not wish to be treated by

I am receiving other treatment or care from providers who I feel have an impact on my mental health care. I would like the following treatment provider(s) to be contacted when this directive is effective:

. . . . . . I consent, and authorize my agent (if appointed) to consent, to the following medications: 

. . . . . . I do not consent, and I do not authorize my agent (if appointed) to consent, to the administration of the following medications: 

. . . . . . I am willing to take the medications excluded above if my only reason for excluding them is the side effects which include:

and these side effects can be eliminated by dosage adjustment or other means

. . . . . . I am willing to try any other medication the hospital doctor, physician assistant, or advanced registered nurse practitioner recommends.

. . . . . . I am willing to try any other medications my outpatient doctor, physician assistant, or advanced registered nurse practitioner recommends.

. . . . . . I do not want to try any other medications.

Medication Allergies.

I have allergies to, or severe side effects from, the following: 

Other Medication Preferences or Instructions

. . . . . . I have the following other preferences or instructions about medications: 

(check all that apply and, if desired, rank "1" for first choice, "2" for second choice, and so on)

. . . . . . In the event my psychiatric condition is serious enough to require 24-hour care and I have no physical conditions that require immediate access to emergency medical care, I prefer to receive this care in programs/facilities designed as alternatives to psychiatric hospitalizations.

. . . . . . I would also like the interventions below to be tried before hospitalization is considered:

. . . . . . Calling someone or having someone call me when needed.

Name:. . . . Telephone/text:. . . . Email:. . . .

. . . . . . Staying overnight with someone

Name:. . . . Telephone/text:. . . . Email:. . . .

. . . . . . Having a mental health service provider come to see me.

. . . . . . Going to a crisis triage center or emergency room.

. . . . . . Staying overnight at a crisis respite (temporary) bed.

. . . . . . Seeing a service provider for help with psychiatric medications.

. . . . . . Other, specify:

Authority to Consent to Inpatient Treatment

I consent, and authorize my agent (if appointed) to consent, to voluntary admission to inpatient mental health treatment for ...... days (not to exceed 14 days).

(Sign one): . . . .

 

. . . . . . If deemed appropriate by my agent (if appointed) and treating physician, physician assistant, or advanced registered nurse practitioner

. . . .

(Signature)

 

Or

 

. . . . . . Under the following circumstances (specify symptoms, behaviors, or circumstances that indicate the need for hospitalization)

. . . .

(Signature)

 

. . . . . . I do not consent, or authorize my agent (if appointed) to consent, to inpatient treatment

. . . .

(Signature)

 

Hospital Preferences and Instructions

If hospitalization is required, I prefer the following hospitals:

I do not consent to be admitted to the following hospitals:

I would like the interventions below to be tried before use of seclusion or restraint is considered (check all that apply):

. . . . . . "Talk me down" one-on-one

. . . . . . More medication

. . . . . . Time out/privacy

. . . . . . Show of authority/force

. . . . . . Shift my attention to something else

. . . . . . Set firm limits on my behavior

. . . . . . Help me to discuss/vent feelings

. . . . . . Decrease stimulation

. . . . . . Offer to have neutral person settle dispute

. . . . . . Other:

If it is determined that I am engaging in behavior that requires seclusion, physical restraint, and/or emergency use of medication, I prefer these interventions in the order I have chosen (choose "1" for first choice, "2" for second choice, and so on):

. . . . . . Seclusion

. . . . . . Seclusion and physical restraint (combined)

. . . . . . Medication by injection

. . . . . . Medication in pill or liquid form

In the event that my attending physician, physician assistant, or advanced registered nurse practitioner decides to use medication in response to an emergency situation after due consideration of my preferences and instructions for emergency treatments stated above, I expect the choice of medication to reflect any preferences and instructions I have expressed in Part VI C. of this form. The preferences and instructions I express in this section regarding medication in emergency situations do not constitute consent to use of the medication for nonemergency treatment.

My wishes regarding electroconvulsive therapy are (sign one):

. . . . . .I do not consent, nor authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy

. . . .

(Signature)

 

. . . . . . I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy

. . . .

(Signature)

 

. . . . . . I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy, but only under the following conditions: 

. . . .

(Signature)

 

Name: . . . .

 

Name: . . . .

 

I understand that persons not listed above may be permitted to visit me.

Other instructions about my mental health care:

In case of emergency, please contact:

Name: . . . .

Work telephone: . . . .

Physician, physician assistant, or advanced registered nurse practitioner: . . . .

Telephone: . . . .

Address: . . . .

Home telephone: . . . .

Address: . . . .

Email: . . . .

The following may help me to avoid a hospitalization:

I generally react to being hospitalized as follows:

Staff of the hospital or crisis unit can help me by doing the following:

I do not consent to any mental health treatment.

. . . .

(Signature)

 

(Fill out this part only if you wish to appoint an agent or nominate a guardian.)

I authorize an agent to make mental health treatment decisions on my behalf. The authority granted to my agent includes the right to consent, refuse consent, or withdraw consent to any mental health care, treatment, service, or procedure, consistent with any instructions and/or limitations I have set forth in this directive. I intend that those decisions should be made in accordance with my expressed wishes as set forth in this document. If I have not expressed a choice in this document and my agent does not otherwise know my wishes, I authorize my agent to make the decision that my agent determines is in my best interest. This agency shall not be affected by my incapacity. Unless I state otherwise in this durable power of attorney, I may revoke it unless prohibited by other state law.

Name: . . . .

Address: . . . .

Work phone: . . . .

Home/cell phone: . . . .

Relationship: . . . .

Email: . . . .

If the person named above is unavailable, unable, or refuses to serve as my agent, or I revoke that person's authority to serve as my agent, I hereby appoint the following person as my alternate agent and request that this person be notified immediately when this directive becomes effective or when my original agent is no longer my agent:

Name: . . . .

Address: . . . .

Work phone: . . . .

Home phone: . . . .

Relationship: . . . .

Email: . . . .

I do not grant my agent the authority to consent on my behalf to the following:

I choose to limit my ability to revoke this durable power of attorney as follows:

In the event a court appoints a guardian who will make decisions regarding my mental health treatment, I nominate my then-serving agent (or name someone else) as my guardian:

Name and contact information (if someone other than agent or alternate):

 

The appointment of a guardian of my estate or my person or any other decision maker shall not give the guardian or decision maker the power to revoke, suspend, or terminate this directive or the powers of my agent, except as authorized by law.

(Initial all that apply)

I have executed the following documents that include the power to make decisions regarding health care services for myself:

. . . . . . Health care power of attorney (chapter 11.125 RCW)

. . . . . . "Living will" (Health care directive; chapter 70.122 RCW)

. . . . . . I have appointed more than one agent. I understand that the most recently appointed agent controls except as stated below:

(Fill out this part only if you wish to provide nontreatment instructions.)

I understand the preferences and instructions in this part are NOT the responsibility of my treatment provider and that no treatment provider is required to act on them.

I desire my agent to notify the following individuals as soon as possible if I am admitted to a mental health facility:

Name: . . . .

Address: . . . .

Day telephone: . . . .

Evening telephone: . . . .

Name: . . . .

Address: . . . .

Day telephone: . . . .

Evening telephone: . . . .

Name: . . . .

Address: . . . .

Day telephone: . . . .

Evening telephone: . . . .

I have the following preferences or instructions about my personal affairs (e.g., care of dependents, pets, household) if I am admitted to a mental health treatment facility: 

By signing here, I indicate that I understand the purpose and effect of this document and that I am giving my informed consent to the treatments and/or admission to which I have consented or authorized my agent to consent in this directive. I intend that my consent in this directive be construed as being consistent with the elements of informed consent under chapter 7.70 RCW.

In witness of this, I have signed on this . . . . . . day of . . . . . ., 20. . . .

Signature: . . . .

 

STATE OF WASHINGTON )

) ss.

COUNTY OF . . . .)

I certify that I know or have satisfactory evidence that (client name) is the person who appeared before me, and said person acknowledged that he or she signed this Durable Power of Attorney and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in this instrument.

SUBSCRIBED and SWORN to before me this . . . . . . day of . . . . . ., 20. . . .

 

. . . .

SIGNATURE OF NOTARY

 

 

This directive was signed and declared by the "Principal," to be his or her directive, in our presence who, at his or her request, have signed our names below as witnesses. We declare that, at the time of the creation of this instrument, the Principal is personally known to us, and, according to our best knowledge and belief, has capacity at this time and does not appear to be acting under duress, undue influence, or fraud. We further declare that none of us is:

(A) A person designated to make medical decisions on the principal's behalf;

(B) A health care provider or professional person directly involved with the provision of care to the principal at the time the directive is executed;

(C) An owner, operator, employee, or relative of an owner or operator of a health care facility or long-term care facility in which the principal is a patient or resident;

(D) A person who is related by blood, marriage, or adoption to the person, or with whom the principal has a dating relationship as defined in RCW 7.105.010;

(E) An incapacitated person;

(F) A person who would benefit financially if the principal undergoes mental health treatment; or

(G) A minor.

Witness 1 Signature: . . . .

Date: . . . .

Printed Name: . . . .

Address: . . . .

Telephone: . . . .

 

Witness 2 Signature: . . . .

Date: . . . .

Printed Name: . . . .

Address: . . . .

Telephone: . . . .

 

I have given a copy of this directive to the following persons:

 

Name: . . . .

Address: . . . .

Day telephone: . . . .

Evening telephone: . . . .

Name: . . . .

Address: . . . .

Day telephone: . . . .

Evening telephone: . . . .

 

. . . . . . I am revoking the following part(s) of this directive (specify):

 

Date: . . . . . . . . .

. . . . . . I am revoking all of this directive.

By signing here, I indicate that I understand the purpose and effect of my revocation and that no person is bound by any revoked provision(s). I intend this revocation to be interpreted as if I had never completed the revoked provision(s).

. . . .

(Signature)

 

Printed Name: . . . .