Declaration For Mental Health Treatment printable pdf download

Declaration For Mental Health Treatment

Declaration for Mental Health Treatment

I, __________________, being an adult of sound mind, wilfully and voluntarily make this

declaration for mental health treatment to be followed if it is determined by a court that my

ability to understand the nature and consequences of a proposed treatment, including the

benefits, risks, and alternatives to the proposed treatment, is impaired to such an extent that I

lack the capacity to make mental health treatment decisions. "Mental health treatment" means

electroconvulsive or other convulsive treatment, treatment of mental illness with psychoactive

medication, and preferences regarding emergency mental health treatment.

(OPTIONAL PARAGRAPH) I understand that I may become incapable of giving or withholding

informed consent for mental health treatment due to the symptoms of a diagnosed mental

disorder. These symptoms may include: ____________________________________________

Psychoactive Medications

If I become incapable of giving or withholding informed consent for mental health treatment, my

wishes regarding psychoactive medications are as follows:

_____ I consent to the administration of the following medications: ______________________

_____ I do not consent to the administration of the following medications: _________________

_____ I consent to the administration of a federal Food and Drug Administration approved

medication that was only approved and in existence after my declaration and that is considered in

the same class of psychoactive medications as stated below: ____________________________

Conditions or limitations: ________________________________________________________

Convulsive Treatment

If I become incapable of giving or withholding informed consent for mental health treatment, my

wishes regarding convulsive treatment are as follows:

_____ I consent to the administration of convulsive treatment.

_____ I do not consent to the administration of convulsive treatment.

Conditions or limitations: _______________________________________________________

Preferences for Emergency Treatment

In an emergency, I prefer the following treatment FIRST (circle one):

Restraint/Seclusion/Medication.

Declaration For Mental Health Treatment