Home
The Handbook:
Table of Contents
Introduction
Brain Disorders
Coping in Crisis
Medications
Resources for Care
Effects on the Family
Public Health Services
Financial Resources
Working with the System
Appendices:
NAMI Phone Numbers
DuPage Health Services
Chicago Area Hospitals
Community Resources
Legal Resources
Books, Videos, Journals
Hospitalization Form
Judicial Admission Form
Declaration of Treatment
Drug Reimbursement
An Affiliate of the National Alliance on Mental Illness
Notice to Persons Making a Declaration for Mental Health Treatment
This is an important legal document. It creates a declaration for mental health treatment. Before signing this document you should know these important facts.
This document allows you to make decisions in advance about 3 types of mental health treatment: psychotropic medication, electroconvulsive therapy and short term (up to 17 days) admission to a treatment facility. The instructions that you include in this declaration will followed only if 2 physicians or the court believes that you are incapable of making treatment decisions. Otherwise you will be considered capable to give or withhold consent for treatments.
You may also appoint a person as your attorney-in-fact to make these decisions for you if you become incapable. The person appointed has a duty to act consistent with your desires as stated in this document or otherwise made known to the attorney-in-fact to act in a manner consistent with what the person in good faith believes to be in your best interest. For the appointment to be effective, the person you appoint must accept the appointment in writing. He also has the right to withdraw from acting as your attorney-in-fact at any time.
This document will continue in effect for 3 years unless you become incapable of participating in mental health decisions. If this occurs, the directive will be continue in effect until you are no longer incapable.
You have the right to revoke this document in whole or in part at any time you have been determined by a physician to be capable of giving or withholding informed consent for mental health treatment. A revocation is effective when it is communicated to your attending physician in writing and is signed by you and a physician. A revocation may be in the form of the following:
REVOCATION
I, ___________________________, willfully and voluntarily revoke my declaration for mental health treatment as indicated
( ) I revoke my entire declaration
( ) I revoke the following portion of my declaration
___________________________________________________________________________
___________________________________________________________________________
Date_______________Signed__________________________________________(Signature of Principal) I, Dr.______________________________, have evaluated the principal and determined that he or she is capable of giving or withholding unformed consent for mental health treatment.
Date_______________Signed___________________________________________________
Signature of Principal) I, Dr.______________________________, have evaluated the principal and determined that he or she is capable of giving or withholding unformed consent for mental health treatment.
Date_______________Signed___________________________________________________
(Signature of Physician) If there is anything in this document that you do not understand you should ask a lawyer to explain it to you. This declaration will not be valid unless it is signed by two witnesses who are personally known to you and who are present when you sign or acknowledge your signature.
Declaration for Mental Health Treatment
I__________________________ being an adult of sound mind, willfully and voluntarily make this declaration for mental health treatment to be followed if it is determined by two physicians or the court that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack capacity to refuse or accept mental health treatment. "Mental Health Treatment" means electroconvulsive treatment, treatment of mental illness with psychotropic malfunction and admission to and retention in a health care facility for up to 17 days. I understand that I may become incapable of giving or withholding informed consent due to the symptoms of a diagnosed mental disorder. These symptoms may include______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
PSYCHOTROPIC MEDICATIONS
If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychotropic medications are as follows:
I consent to the administration of the following medications:___________ ________________________________________________________________________________________________________________________
I do not consent to the administration of the following medications:_____
____________________________________________________________
___________________________________________________________________________
Conditions or Limitations:_______________________________________
____________________________________________________________
ELECTROCONVULSIVE TREATMENT
If I become incapable of giving or withholding informed consent for mental health treatment my wishes regarding electroconvulsive treatment are as follows:
____ I consent to the administration of electroconvulisve treatment.
____ I do not consent to the administration of electroconvulsive treatment.
Conditions or Limitations:_______________________________________
ADMISSION TO A RETENTION FACILITY
If I become incapable of giving or withholding informed consent for mental health treatment my wishes regarding psychotropic medications are as follows:
____ I consent to being admitted to a health care facility for mental health treatment.
____ I do not consent to being admitted to a health care facility for mental health treatment.
This directive cannot, by law, provide consent to retain me in a facility for more than 17 days.
Conditions or Limitations:_____________________________________________________
__________________________________________________________________________
SELECTION OF A PHYSICIAN
If it becomes necessary to determine if I have become incapable of giving or withholding informed consent for mental health treatment, I choose Dr.__________________________of
______________________________to be one of the two physicians who will determine whether I am incapable. If that physician is unavailable, that physician's designee shall determine whether I am incapable.
ATTORNEY-IN-FACT
I hereby appoint:
Name__________________________________________________________
Address________________________________________________________
________________________________________________________
Telephone # ____________________________________________________
To act as my attorney- in-fact to make decisions regarding my mental health treatment if I become incapable of giving or withholding informed consent for that treatment.
If the person named above refuses or is unable to act on my behalf, or if I revoke that person's authority to act as my attorney-in-fact, I authorize the following person to act as my attorney-in-fact:
Name__________________________________________________________
Address________________________________________________________
________________________________________________________
Telephone # ____________________________________________________
My attorney-in-fact is authorized to make decisions that are consistent with the wishes I have expressed in this declaration or, if not expressed, as are otherwise known to my attorney-in-fact. If my wishes are not expressed and are not otherwise known to my attorney-in-fact, my attorney-in-fact is to act in what he or she believes to be my best interest.
________________________________________________________________
Signature of Principal / Date
ACCEPTANCE OF APPOINTMENT AS ATTORNEY IN FACT
I accept this appointment and agree to serve as attorney-in-fact to make decisions about mental health treatment for the principal. I understand that I have a duty to act consistent with the desires of the principal as expresses in this appointment. I understand that this gives me authority to make decisions about mental health treatment only while the principal is incapable as determined by a court or two physicians. I understand that the principal may revoke this declaration in whole or in part at any time and in any manner when the principal is not incapable.
________________________________________________________________
Signature of Attorney-in-fact / Date
________________________________________________________________
Signature of Alternate Attorney-in-fact / Date
AFFIRMATION OF WITNESSES
We affirm that the principal is personally known to us, that the principal signed or acknowledge the principal's signature on this declaration for mental health treatment in our presence, that the principal appears to be of sound mind and not under duress, fraud, or undue influence, that neither of us is:
A person appointed as an attorney-in-fact by this document;
The principal's attending physician, mental health service provider, or a relative of the physician or provider;
The owner operator or relative of an own6er or operator lf a facility in which theprincipal is a patient or resident; or
A person related to the principal by blood, marriage, or adoption
Witnessed by:
................. .............
(Signature of Witness/Date (Printed name of Witness) __
................ ............
(Signature of Witness/Date (Printed name of Witness)
Previous | Top of Page | Next