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

Advance Directive For Mental Health Treatment Page 3

____________________________________________________________________

I DO NOT want to be treated at the following facilities:

(consider giving reasons)

____________________________________________________________________

List the names and contact information for your mental health treatment

team:

Psychiatrist Name: _________________________________________________

Psychiatrist Phone: ________________________________________________

Therapist Name: __________________________________________________

Therapist Number: _________________________________________________

Case Manager Name: ______________________________________________

Case Manager Phone: ______________________________________________

Other names and numbers: _________________________________________

________________________________________________________________

I give permission for the following people to visit me in the treatment

facility:

________________________________________________________________

Advance Directive For Mental Health Treatment Page 3