Mental Health Advance Directive Form printable pdf download

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, then completing a mental health advance directive will ensure that your

treatment choices are 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 may

always change your preferences or surrogate later.

You can use the following Advance Directive form to direct your future care.

Read each section of the form carefully and talk about your choices with someone you trust.

The person you choose to be your health care surrogate and alternate must be a competent adult whose civil

rights have not been taken away. The person you choose should not be a mental health professional, an

employee of a facility that might provide services to you, an employee of the Department of Children & Family

Services or a member of the Local Advocacy Council.

You should sign the form in front of two witnesses.

Make sure your surrogate understands your wishes and is willing to accept the responsibility. Your surrogate

(and a back-up alternate surrogate if you wish) should sign this form now or at a later time to show they are

aware you have chosen them to be your surrogate.

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 treated, your family and anyone else who might be involved in your care.

Discuss your choices with each of them.

The document should be available quickly if you need it. If you travel, be sure to take a copy with you.

Your advance directive will not take effect unless a physician decides that you are not competent to make your own

treatment decisions. If you are in a psychiatric facility, you will have an attorney appointed to represent your interests

and 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.

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Mental Health Advance Directive Form