Declaration For Mental Health Treatment (Page 2 of 4) in pdf

Declaration For Mental Health Treatment Page 2

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

Restraint/Seclusion/Medication.

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

Restraint/Seclusion/Medication.

______ I prefer a male/female to administer restraint, seclusion, and/or medications.

Options for treatment prior to use of restraint, seclusion, and/or medications:

________________________________________________________________________

Conditions or limitations: ___________________________________________________

Additional Preferences or Instructions

________________________________________________________________________

Conditions or limitations: ___________________________________________________

Signature of Principal/Date: _________________________________________________

Signature Acknowledged Before Notary Public

State of Texas

County of_________

This instrument was acknowledged before me on ______(date) by ___________(name of notary

public) [Note: “(name of notary public)” is in the statutory form, but it should be (“name of

prinicipal”)].

____________________________

NOTARY PUBLIC, State of Texas

Printed name of Notary Public:

____________________________

My commission expires:

____________________________

Signature in Presence of Two Witnesses

STATEMENT OF WITNESSES

I declare under penalty of perjury that the principal's name has been represented to me by the

principal, that the principal signed or acknowledged this declaration in my presence, that I

believe the principal to be of sound mind, that the principal has affirmed that the principal is

Declaration for Mental Health Treatment

Page 2

Declaration For Mental Health Treatment Page 2