Advance Directive For Mental Health Treatment Page 5
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5________________________________________________________________
________________________________________________________________
The following people may be given information about my condition and
treatment(s):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________
__________________________
Signature of patient
Printed Name and Date
__________________________
__________________________
Signature of witness
Printed Name and Date
__________________________
__________________________
Signature of witness
Printed Name and Date
__________________________
__________________________
Signature of health care provider
Printed Name and Date
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Parent category: Medical