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I, , having capacity to make mental health decisions, willfully and voluntarily make this declaration and power of attorney regarding my mental health care. I understand that mental health care includes any care, treatment, service or procedure to maintain, diagnose, treat or provide for mental health, including any medication program and therapeutic treatment. Electroconvulsive therapy may be administered only if I have specifically consented to it in this document. I will be the subject of laboratory trials or research only if specifically provided for in this document. Mental health care does not include psychosurgery or termination of parental rights.
I understand that my incapacity will be determined by examination by a psychiatrist and one of the following: another psychiatrist, psychologist, family physician, attending physician or mental health treatment professional. Whenever possible, one of the decision makers will be one of my treating professionals.
| Part II. | Mental Health Declaration |
A. When this Declaration Becomes Effective.
This declaration becomes effective
B. Treatment Preferences.
1. Preferences regarding medications for psychiatric treatment.
2. Preferences regarding electroconvulsive therapy (ECT).
3. Preferences for experimental studies or drug trials.
C. Revocation.
This declaration may be revoked in whole or in part at any time, either orally or in writing, as long as I have not been found to be incapable of making mental health decisions.
My revocation will be effective upon communication to my attending physician or other mental health care provider, either by me or a witness to my revocation, of the intent to revoke. If I choose to revoke a particular instruction contained in this power of attorney in the manner specified, I understand that the other instructions contained in this power of attorney will remain effective until:
(1) I revoke this declaration in its entirety;
(2) I make a new
(3) two years after the date this document was executed.
D. Termination.
I understand that this declaration will automatically terminate two years from the date of execution unless I am deemed incapable of making mental health care decisions at the time this declaration would expire.
Date of Signing
The appointment of a guardian of my person will not give the guardian the power to revoke, suspend or terminate this declaration.
Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate this declaration.
when I am deemed incapable of making mental health care decisions.when the following condition is met:
My agent is authorized to consent to the use of any medications after consultation with my treating psychiatrist and any other person my agent considers appropriate.
My agent is not authorized to consent to the use of any medications.
My agent is authorized to consent to the administration of electroconvulsive therapy.
My agent is not authorized to consent to the administration of electroconvulsive therapy.
My agent is authorized to consent to my participation in experimental studies if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believes that the potential benefits to me outweigh the possible risks to me.
My agent is not authorized to consent to my participation in experimental studies.
My agent is authorized to consent to my participation in drug trials if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believes that the potential benefits to me outweigh the possible risks to me.
My agent is not authorized to consent to my participation in drug trials.
I am making this on .
| My Signature: |
____________________________________
County
,
Home Phone: Work Phone:
| Witnesses signatures: |
| ___________________________________ | ___________________________________ |
| , |
| _____ | (your Agent) |
_____ (your Alternate Agent)
| * | You should 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. |
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It's simple and easy to assign or receive the support you may need using a free Mental Health Declaration and Power of Attorney template from Rocket Lawyer:
This route is often notably more affordable and convenient than finding and hiring the average law firm. If necessary, you can start this medical PoA on behalf of your spouse or another family member, and then have them sign it once you've drafted it. Please remember that for this document to be considered valid, the principal must be a mentally competent adult when they sign. If the principal has already been declared incompetent, a court-appointed conservatorship may be necessary. In such a situation, it is a good idea for you to speak with an attorney .
Every person over 18 years old should have a Healthcare Power of Attorney. While it may be tough to think about, there may come a day when you can no longer make your own medical decisions. Here are some typical situations where power of attorney might be useful:
Regardless of whether this Mental Health Declaration and Power of Attorney has been prepared as part of a forward-looking plan or created as a result of an unexpected issue, witnesses and notarization are strongly recommended as a best practice for protecting your document if its authority is questioned by a third party.
In researching the topics of estate planning and elder care, you might hear "healthcare proxy" and "healthcare power of attorney" being used together or interchangeably. In short, they're the same. That said, it's entirely possible to grant power of attorney over affairs that aren't health-related. In that case, "proxy" generally is not the term of choice.
Mental Health Declaration and PoA forms are generally easy to make; however, you or your agent(s) might have questions. Hiring a legal professional to give feedback on your Healthcare Power of Attorney may take longer than you'd expect if you attempt to do it by yourself. Another approach would be via the Rocket Lawyer On Call® network. Rocket Lawyer Premium members are able to ask for a document review from an Rocket Lawyer network attorney with relevant experience or send other legal questions. As always, you can live confidently with Rocket Lawyer by your side.
The fees associated with working with a conventional law firm to generate a medical Power of Attorney might be anywhere from two hundred to five hundred dollars. When you use Rocket Lawyer, you aren't just filling out a Power of Attorney template. In case you ever need help from a lawyer, your Rocket Lawyer membership offers up to 40% in savings when you hire an attorney from our Rocket Lawyer attorney network.
Your Power of Attorney will come with its own list of instructions on what comes next after your document is finished. You also can take any of the following actions related to your PoA: editing it, saving it as a Word or PDF file, printing it out, and signing it. Finally, make sure to send a copy of your signed document to your agent(s) and care providers.
The guidelines and restrictions for PoA forms will be different in each state; however, it is highly encouraged to have your Power of Attorney signed by at least one witness and/or notarized in order to reinforce its credibility. As a general rule, witnesses will need to be over 18 years old, and none of them should also be your agent.
