Mental Health Advance Directive Form

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Mental Health Advance Directive
If you believe you may be hospitalized for mental health care in the future and that your doctor may think you aren’t able to make
good decisions about your treatment, completion of a mental health advance directive will help make your treatment preferences
known. It is important that you decide NOW what types of treatment you do or do not want and to appoint a friend or family member
to make the mental health care decisions that you want carried out.
You can use the following advance directive form to direct your future care.
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Read each section of the form carefully and talk about your choices with your case manager, doctor, or other trusted persons.
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The person you choose to be your health care surrogate and alternate must be a competent person who is at least 18 years old,
whose civil rights have not been taken away. The person you choose should not be a mental health professional, an employee of
a facility which might provide services to you, an employee of the Department of Children & Family Services, or a member of the
Local Advocacy Council.
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Make sure your surrogate understands your wishes and is willing to take the responsibility.
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You and your surrogate (and a back-up alternate surrogate if you wish) should sign the form in front of two witnesses.
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Have copies made and give them to your surrogate, your case manager, your doctor, the hospital or crisis unit at which you are
most likely be taken, your family, and anyone else who might be involved in your care. Discuss your choices with each of them.
You can change your advance directive at anytime you are competent to do so. If you travel, be sure to take a copy of the advance
directive with you. Your advance directive will not take effect unless a physician decides that you are incompetent to make your own
treatment decisions. If you are in a psychiatric facility, you will have an attorney appointed to represent your interests, and will have
a hearing in front of a judge or hearing master. A health care surrogate is not authorized to consent to treatment for a person on
voluntary status.
I, ____________________________________________, being of sound mind, willfully and voluntarily execute this mental health
advance directive to assure that if I should be found incompetent to consent to my own mental health treatment, my choices regarding
my treatment will be carried out despite my inability to make informed decisions for myself.
If a guardian or other decision-maker is appointed by a court to make health care or mental health decisions for me, I intend this
document to take precedence over all other means of determining my intent while competent. This document represents my wishes
and it should be given the greatest possible legal weight and respect. If the surrogate(s) named in this directive are not available, my
wishes shall be binding on whoever is appointed to make such decisions.
If I become incompetent to make decisions about my own mental health treatment, I have authorized a mental health care surrogate
to make certain treatment decisions for me. My surrogate is also authorized to apply for public benefits to defray the cost of my health
care, to release information to appropriate persons, and to authorize my transfer from a health care facility.
My mental health care surrogate is:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Day Telephone: ________________________ Evening Telephone: ________________________
CONTINUED
Baker Act Handbook and User Reference Guide / 2002
State of Florida Department of Children & Families

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