Mental Health Advance Directive Form (Page 3 of 5) in pdf

D. My wishes about confidentiality of my admission to a facility and my treatment while there are as follows:

1. My representative may be notified of my involuntary admission ___ Yes ___ No

2. Any person who seeks to contact me while I am in a facility may be told I am there. __ Yes __ No

3. I consent to release of information about my condition and treatment plan to the following persons:

______________________________________ ______________________________________

4. If I am incompetent to give consent, I want staff to immediately notify the following persons that I have been

admitted to a psychiatric facility.

Name: _______________________________________ Relationship:____________________

Address:_____________________________________________________________________

Day Phone: _____________________________ Evening Phone: ________________________

Name: _______________________________________ Relationship:____________________

Address:_____________________________________________________________________

Day Phone: _____________________________ Evening Phone: ________________________

Name: _______________________________________ Relationship:____________________

Address:_____________________________________________________________________

Day Phone: _____________________________ Evening Phone: ________________________

E. If I am not competent to consent to my own treatment or to refuse medications relating to my mental health

treatment, I have initialed one of the following, which represents my wishes:

_____I consent to the medications that Dr. ________________________________ recommends.

_____I consent to the medications agreed to by my mental health care surrogate after consulting with my

treating physician and any other individuals my surrogate deems appropriate, with the exceptions found in #3

below.

_____I specifically do not consent and I do not authorize my mental health care surrogate to consent to the

administration of the following medications or their respective brand name, trade name or generic equivalents:

(list name of drug and reason for refusal):

________________________________________________________________________________

_____I am willing to take the medications excluded in #3 above if my only reason for excluding them is their

side effects and the dosage can be adjusted to eliminate those side effects.

Page 3 of 5 10/08/05

Mental Health Advance Directive Form Page 3