Mental Health Advance Directive (Baker Act Handbook And User Reference Guide) Form Page 3
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4D.
My wishes regarding confidentiality of my admission to a facility and my treatment while there are as follows:
1.
_____My representative may be notified of my involuntary admission ___Yes
___No
2.
_____Any person who seeks to contact me while I am in a facility may be told I am there. ___Yes
___No
3.
_____I consent to release of information about my condition and treatment plan ___Yes
___No
To the following persons: ____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
4.
_____I do not consent to the release of information about my admission or treatment to anyone unless I give
specific consent at the time of the request or as otherwise allowed by law. ___Yes
___No
E.
If I am not competent to consent to my own treatment or to refuse medications relating to my mental health treatment, I have
initialed one of the following, which represents my wishes:
1.
_____ I consent to the medications that Dr. __________________________ recommends.
2.
_____ I consent to the medications agreed to by my mental health care surrogate, after consulting with my treating
physician and any other individuals my surrogate may think appropriate, with the exceptions found in #3 below.
3.
_____ I specifically do not consent and I do not authorize my mental health care surrogate to consent to the
administration of the following medications or their respective brand name, trade name, or generic equivalents:
(list name of drug and reason for refusal
__________________________________________________________________________________
__________________________________________________________________________________
4.
_____ I am willing to take the medications excluded in #3 above if my only reason for excluding them is their side
effects and the dosage can be adjusted to eliminate those side effects.
5.
I have the following other preferences about psychiatric medications:
_________________________________________________________________________________________
_________________________________________________________________________________________
F.
My wishes regarding Electroconvulsive Therapy (ECT) are as follows:
1.
_____ My surrogate may not consent to ECT without express court approval.
2.
_____ I authorize my surrogate to consent to ECT.
3.
Other instructions and wishes regarding ECT are as follows:
_______________________________________________________________________
_______________________________________________________________________
G.
If, during a stay in a psychiatric facility, my behavior requires an emergency intervention, my wishes regarding which form
of emergency interventions should be made in the following order: (fill in numbers, giving 1 to your first choice, 2 to your
second, and so on until each has a number). If an intervention you prefer is not listed, write it in after “other” and give it a
number.
___Seclusion
___ Medication in pill form
___ Physical restraints
___ Medication in liquid medication
___ Both seclusion and physical restraints
___ Medication by injection
___ Other:
___ __________________
___ __________________
___ __________________
___ __________________
CONTINUED PAGE 3
Baker Act Handbook and User Reference Guide / 2002
State of Florida Department of Children & Families
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