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Sample Mental Health Power of Attorney Form Template
Mental Health Power of Attorney Basics

When you can't look out for yourself, make sure a loved-one is taking care of your mental health. Create a Mental Health Power of Attorney to designate a family member, spouse or trusted friend to make your mental health decisions when you no longer can.

Use the Mental Health Power of Attorney document if:

  • You want to designate someone to make decisions for your mental health care if you are unable to do so yourself.
  • You anticipate treatment in a mental health facility.
  • Your mental health is declining or you have been diagnosed with a condition that may lead the inability to make mental health care decisions for yourself.


Sample Mental Health Power of Attorney

More than just a template, our step-by-step interview process makes it easy to create a Mental Health Power of Attorney.

Save, sign, print, and download your document when you are done.


A Mental Health Power of Attorney allows you to designate a trusted person (your "Agent") to make mental health care decisions on your behalf. When a doctor has determined you no longer have the capacity to make decisions for yourself, this document will go into effect. With a Mental Health Power of Attorney you can provide your Agent with guidance by stating your preferences for certain treatments, medical decisions and medications. However, by signing this Mental Health Power of Attorney, your Agent will have their own discretion to make medical decisions concerning your mental health. If you wish to state your preferences for your mental health care treatment or want to state your preferences as well as designate an agent, use the Mental Health Declaration and Power of Attorney form.

Other names for this document: Mental Health Care Power of Attorney, Mental Health POA

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