Mental Health Advance Directive (Baker Act Handbook And User Reference Guide) Form Page 4
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4H.
Florida law prohibits a mental health care surrogate from consenting to experimental treatments that have not been approved
by a federally approved institutional review board without my prior written consent or the express approval of the court.
_____ I consent to my participation in experimental drug studies or drug trials
_____ I do not wish to participate in experimental drug studies or drug trials
I.
If I am incompetent to give consent, I want staff to immediately notify the following persons that I have been admitted to a
psychiatric facility.
Name: ___________________________________
Relationship: ____________________
Address: __________________________________________________________________
Day Phone: ________________________ Evening Phone: _________________________
Name: __________________________________
Relationship: ____________________
Address: __________________________________________________________________
Day Phone: ________________________ Evening Phone: __________________________
J.
Other instructions I wish to make about my mental health care are (use additional pages if needed):
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________
By signing here I indicate that I fully understand that this advance directive will permit my mental health care surrogate to make
decisions and to provide, withhold, or withdraw consent for my mental health treatment.
Printed Name (Declarant): ________________________________________________________
Signature: ____________________________________________Date: ____________________
This advance directive was signed by _____________________________ in our presence. At his/her request, we have signed our names
below as witness. We declare that, at the time this advance directive was signed, the Declarant, according to our best knowledge and
belief was of sound mind and under no constraint or undue influence. We further declare that we are both adults, are not designated in this
advance directive as the mental health care surrogate, and at least one of us is neither the person’s spouse nor blood relative.
Dated at _______________, this __________day of _____________, _________.
(County & State)
(Day)
(Month)
(Year)
Witness Signatures:
Witness 1:
Witness 2:
_________________________________
___________________________
Signature of witness 1
Signature of witness 2
_________________________________
___________________________
Printed name of witness 1
Printed name of witness 2
_________________________________
___________________________
Home address of witness 1
Home address of witness 2
_______________________________
__________________________
City, State, Zip Code of witness 1
City, State, Zip Code of witness 2
PAGE 4
Baker Act Handbook and User Reference Guide / 2002
State of Florida Department of Children & Families
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