Advance Directive For Mental Health Treatment

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Advance Directive for Mental Health Treatment
This document is to be used as an example only. Please contact your state's
Protection and Advocacy
Program, a lawyer, paralegal, or advocate
to create a legally binding document.
My Name: _______________________________________________________
Symptoms that tell me I may not be capable of making decisions for
myself:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
I appoint the following person to act as my representative to make
decisions about my mental health care if I become incapable:
Name: __________________________________________________________
Address: ________________________________________________________
________________________________________________________
Phone: __________________________________________________________
If the above person is not available or refuses to act on my behalf, the
following person can act on my behalf:
Name: __________________________________________________________
Address: ________________________________________________________
________________________________________________________
Phone: __________________________________________________________

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