Mental Health Advance Directive (Baker Act Handbook And User Reference Guide) Form (Page 2 of 4) in pdf

I,____________________________________________, mental health care surrogate designated by

____________________________________________, hereby accept the designation.

_____________________________________________

__________________________

(Signature of Mental Health Care Surrogate)

(Date)

If the person named above is unavailable or unable to serve as my mental health care surrogate, I hereby appoint and want immediate

notification of my alternate mental health care surrogate as follows:

Name of Alternate: ______________________________________________________________

Address: ______________________________________________________________________

Day Telephone: ________________________ Evening Telephone: ________________________

I, __________________________________________, alternate mental health care surrogate designated by

__________________________________________, hereby accept the designation.

_____________________________________________

_________________________

(Signature of Alternate Mental Health Care Surrogate)

(Date)

Complete the following or Initial in the blank marked yes or no:

If I become incompetent to give consent to mental health treatment, I give my mental health care surrogate full power and

authority to make mental health care decisions for me. This 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

stated in this advance directive. If I have not expressed a choice in this advance directive, I authorize my surrogate to make

the decision my surrogate determines is the decision I would make if I were competent to do so. _____Yes ____No

My choice of treatment facilities are as follows:

In the event my psychiatric condition is serious enough to require 24-hour care, I would prefer to receive this

care in this/these facilities:

Facility: _______________________________________________________________

I do not wish to be placed in the following facilities for psychiatric care for the reasons I have listed:

Facility/Reason: __________________________________________________________

My choice of a treating physician is:

First choice of physician: __________________________________________________

Second choice of physician: ________________________________________________

I do not wish to be treated by the following physicians:

Name of physician: ______________________________________________________

CONTINUED PAGE 2

Baker Act Handbook and User Reference Guide / 2002

State of Florida Department of Children & Families

Mental Health Advance Directive (Baker Act Handbook And User Reference Guide) Form Page 2