Free Mental Health Declaration and Power of Attorney

The person that you designate as the Agent should be someone you know and trust. The statutes of most states require that the Agent be an adult. In addition, under most circumstances, your Agent cannot be your mental health care provider (for example, a psychiatrist, nurse, employee, officer, director, or operator of a mental health agency, hospital, nursing home, or residential care facility), unless that person is related to you. Thus, in selecting an Agent, you should not designate a person who is (or may become) directly involved in providing mental health care to you, unless that person is your spouse or a family member.

If there are two people that you would like to serve as your Agent, you can name one as an alternate Agent.

Generally an Agent will have broad authority (subject to limitations you state in the document) to make mental health care decisions for you. Such decisions might include:

• limitations on medications use to treat your condition

• whether or not electroconvulsive therapy may be used

• whether to consent to experimental treatments or drug trials

In certain situations, depending on specific state law and a person's medical condition, it may be necessary to have a court-appointed guardian. A "guardian or conservator of the person" is a person who is appointed by a court to make decisions for your general welfare if the court has determined that you are no longer competent to make such decisions on your own behalf. The authority of a guardian or conservator to make decisions for your "general welfare" probably includes the power to make at least some kinds of mental health care decisions. Unlike the Agent under a Mental Health Care Power of Attorney, a guardian typically can also make non-health care decisions, such as decisions about living arrangements.

Even though the law requires that guardians be appointed by a court, the court would consider your preferences. In some states' health care directives, you can nominate your choice of a person who would become your guardian or conservator, if that became necessary. In many cases, the person named as the Agent would be the logical choice to serve as the guardian.

The Mental Health Declaration and Power of Attorney allows you to state your preferences for your mental health care treatment. If you wish, you can also use this document to designate another person (your "Agent") to make mental health care decisions for you. You can state preferences here so your agent knows how best to fulfill your wishes.

This document is based on recently passed laws in Pennsylvania which has specifically defined a subset of powers of attorney that address mental health. As such, it is only officially recognized in Pennsylvania. In other states, it may still be used as a way to make sure your wishes are documented and will give you a better chance that your wishes are followed in the event that you are determined incapable.

You may give additional instructions by expressing your wishes in your own words. You may include a statement regarding religious or moral beliefs or that you do (or do not) want to receive certain types of treatment not stated in the document.

You may revoke this document by executing a new document or by stating your intention to revoke it, either orally or in writing. In any event, the document will automatically be revoked two years after execution. However, if the conditions of the Declaration and Power of Attorney are met - you are committed or institutionalized and unable to make decisions - the document remain effective until mental capacity is regained.

Many states specify that a power of attorney may be revoked at any time and in any manner. However, the best method is to provide a written, signed and dated revocation to the Agent (if any) and the appropriate mental health care providers. Although other documents require a witness or notary, legal principles encourage the recognition of a revocation without the necessity of such formalities. NOTE THAT THE REVOCATION DOCUMENT MAY BE CONSIDERED INEFFECTIVE UNTIL YOUR AGENT AND/OR PHYSICIAN HAVE BEEN NOTIFIED OF THE REVOCATION.

1. CAUTION: The document may not be valid in your state of residence unless that state was selected in the program. A lawyer should be consulted if there is any uncertainty regarding which state's document to use.

2. You must be an adult (18 in most states) and mentally competent to execute a valid document. The document must be signed and dated in order to be effective. Depending on your state, the document must be witnessed, notarized, or both. If you designated an Agent, some states require that the Agent also sign the form. Finally, some states require that special provisions within the document be separately initialed or signed. Review the document carefully for these requirements.

3. The specific requirements for who can be a witness, whether the document must be notarized, and other execution formalities are printed on the document itself. The program provides the appropriate signature and witness information.

4. The document must be witnessed by two competent adults (18 or older).

5. The witnesses cannot be the person who signed the declaration at the direction of the declaration.

6. A mental health care provider, or its agent, cannot sign or witness the document.

7. You should initial on the bottom margin of each page of the document. This prevents the subsequent substitution of pages. To print out an initials line at the bottom of each page of your document, go to the "View" menu at the top of the screen and choose "Preferences." Select the "Print" tab and choose the appropriate checkbox.

8. You should keep a copy of the document after signing it. One copy should be given to each of the following: each mental health care provider, appropriate family members, and the person named as Agent and Alternate Agent, if one or both are appointed in the document. An indication should be made on the document itself regarding who has received a copy, in case there is a need for later retrieval, modification, or revocation.

9. Before signing the document, you should be completely comfortable that you understand the nature and range of decisions that may be made on your behalf. You should discuss the range of mental health decisions with a physician or psychiatrist, another mental health care provider, social worker, pastor, or a lawyer -- someone who is knowledgeable about these issues and can answer questions. You should also discuss the document and your wishes with any person you want to designate as an Agent before doing so to assure they agree to act on your behalf.

There are restrictions on who may be a witness to the execution of a Mental Health Care Declaration and Power of Attorney. The witnesses must be capable adults. They cannot be the person signing the document on behalf the person making the declaration and they cannot be a mental health care provider or employee of a mental health care facility.

These restrictions are included in a statement on the document that precedes the signatures of the witnesses. The witness requirements should be carefully reviewed prior to the execution of the document.

Generally, an Agent has broad authority to make almost any decision regarding your mental health care if you are incapable or otherwise unable to communicate your wishes. However, you may limit your Agent's authority. For example, you can state: "My Agent is not authorized to consent to electroconvulsive therapy."

It is not possible to anticipate all of the mental health care decisions that may be required. If you do not provide specific directions regarding a particular mental health care decision, your Agent must act in your best interests and consistent with the laws of your state. You should discuss your wishes, values, and preferences regarding your mental health care with your Agent so that your Agent is best able to make decisions in accordance with your wishes. Your Agent is not liable for mental health care decisions made in good faith.