Declaration For Mental Health Treatment (Page 3 of 4) in pdf

aware of the nature of the document and is signing it voluntarily and free from duress, that the

principal requested that I serve as witness to the principal's execution of this document, and that I

am not a provider of health or residential care to the principal, an employee of a provider of

health or residential care to the principal, an operator of a community health care facility

providing care to the principal, or an employee of an operator of a community health care facility

providing care to the principal.

I declare that I am not related to the principal by blood, marriage, or adoption and that to the best

of my knowledge I am not entitled to and do not have a claim against any part of the estate of the

principal on the death of the principal under a will or by operation of law.

Witness Signature: _____________________________

Print Name: __________________________________

Date: ______________________

Address: _____________________________________

Witness Signature: _____________________________

Print Name: __________________________________

Date: ______________________

Address: _____________________________________

Notice to Person Making a Declaration for Mental Health Treatment

This is an important legal document. It creates a declaration for mental health treatment. Before

signing this document, you should know these important facts:

This document allows you to make decisions in advance about mental health treatment and

specifically three types of mental health treatment: psychoactive medication, convulsive therapy,

and emergency mental health treatment. The instructions that you include in this declaration will

be followed only if a court believes that you are incapacitated to make treatment decisions.

Otherwise, you will be considered able to give or withhold consent for the treatments.

This document will continue in effect for a period of three years unless you become

incapacitated to participate in mental health treatment decisions. If this occurs, the directive will

continue in effect until you are no longer incapacitated.

You have the right to revoke this document in whole or in part at any time you have not been

determined to be incapacitated. YOU MAY NOT REVOKE THIS DECLARATION WHEN

YOU ARE CONSIDERED BY A COURT TO BE INCAPACITATED. A revocation is effective

when it is communicated to your attending physician or other health care provider.

Declaration for Mental Health Treatment

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Declaration For Mental Health Treatment Page 3