Texas Statutory Supported Decision-Making Agreement Form printable pdf download

Texas Statutory Supported Decision-Making Agreement Form

TEXAS STATUTORY SUPPORTED DECISION-MAKING AGREEMENT

NOTICE: This document is explained in the Supported Decision-Making Act, Subtitle I, Title 3, Estates Code. If

you have any questions about this Supported Decision-making Agreement obtain competent legal advice. You

may revoke this supported decision-making agreement later if you wish to do so.

, _______________________________________ (your name), choose to make this agreement

myself. I decided to make this agreement myself and no one told me to make this agreement.

I choose ___________________________________ (name) to be my Supporter.

Supporter Address: ___________________________________

Phone Number: ______________________________________

E-mail Address: ______________________________________

My supporter may help me with life decisions about:

Yes ___No ___ what I eat, what I wear, and where I live

Yes ___No ___ taking care of my health

Yes ___No___ making decisions about money

My supporter does not make decisions for me. My supporter may:

1. Help me get information for medical, psychological, financial, or educational

decisions;

2. Help me understand my choices so I can make the best decision for me; or

3. Help me tell people my decision.

Yes ___No ___ My supporter may see my private health information. (A signed release under

the Health Insurance Portability and Accountability Act of 1996 is attached).

Yes ___No ___ My supporter may see my educational records . (A signed release under the

Family Educational Rights and Privacy Act of 1974 is attached).

This supported decision-making agreement starts when signed and will continue until

________________________ (date) or until the supporter or I end the agreement or the agreement is

ended by law.

Signed this ___________ day of _______________________, ____________

Day

Month

Year

_______________________________________

________________________________

(My Signature)

(My Printed Name)

Texas Statutory Supported Decision-Making Agreement Form