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MENTAL HEALTH CARE POWER OF ATTORNEY
I, , having the capacity to make mental health decisions, authorize my designated health care agent to make certain decisions on my behalf regarding my mental health care. If I have not expressed a choice in this document, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.
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 shall be one of my treating professionals.
A. DESIGNATION OF AGENT.
I hereby designate and appoint the following person as my agent to make mental health care decisions for me as authorized in this document:
| Signed: |
____________________________________
,
| Home Phone: | Work Phone: |
| Witnessed by: |
| ___________________________________ | ___________________________________ |
| , |
| Agent's Acceptance: |
| I hereby accept designation as mental health care agent for . |
| Agent's Signature: |
| ____________________________________ |
,
B. DESIGNATION OF ALTERNATIVE AGENT.
In the event that my first agent is unavailable or unable to serve as my mental health care agent, I hereby designate and appoint the following individual as my alternative mental health care agent to make mental health care decisions for me as authorized in this document:
| Signed: |
____________________________________
,
| Home Phone: | Work Phone: |
| Witnessed by: |
| ___________________________________ | ___________________________________ |
| , |
| Agent's Acceptance: |
| I hereby accept designation as mental health care agent for . |
| Agent's Signature: |
| ____________________________________ |
,
C. WHEN THIS POWER OF ATTORNEY BECOMES EFFECTIVE.
This power of attorney will become effective
D. AUTHORITY GRANTED TO MY MENTAL HEALTH CARE AGENT.
I hereby grant to my agent full power and authority to make mental health care decisions for me consistent with the instructions and limitations set forth in this power of attorney. If I have not expressed a choice in this power of attorney, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.
E. TREATMENT PREFERENCES.
1. Preferences regarding medications for psychiatric treatment.
2. Preferences regarding electroconvulsive therapy (ECT).
3. Preferences for experimental studies or drug trials.
F. REVOCATION.
This power of attorney 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 power of attorney in its entirety;
(2) I make a new mental health power of attorney; or
(3) two years after the date this document was executed.
G. TERMINATION.
I understand that this power of attorney will automatically terminate two years from the date of execution unless I am deemed incapable of making mental health care decisions at the time the power of attorney would expire.
The appointment of a guardian of my person will not give the guardian the power to revoke, suspend or terminate this power of attorney.
Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate this power of attorney.
I making this power of attorney on .
| My Signature: |
____________________________________
County
,
Home Phone: Work Phone:
| Witnessed by: |
| ___________________________________ | ___________________________________ |
| , |
_____ (your Alternate Agent)
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It is fast and simple to assign or receive the support you might need with a free Mental Health Power of Attorney template from Rocket Lawyer:
This method is, in many cases, notably more affordable than finding and working with a conventional attorney. If necessary, you can fill out this Medical PoA on behalf of your spouse or another relative, and then have them sign it after you've drafted it. Please keep in mind that for a Power of Attorney to be considered valid, the principal must be a mentally competent adult when they sign. If the principal has already been declared legally incompetent, a court-appointed conservatorship may be necessary. When facing such a situation, it would be important to speak with a lawyer .
Every adult should have a Healthcare Power of Attorney. Although it may be painful to acknowledge, a time may come when you are not able to make your own medical decisions. Typical occasions where you might consider a PoA to be helpful include:
Regardless of whether this Mental Health Power of Attorney has been prepared as part of a long-term plan or created in response to an unexpected emergency, witnesses and/or notarization are strongly recommended for protecting your document if its lawfulness is questioned by a third party.
In discussing the topics of elder care or estate planning with healthcare or legal professionals, you may find that the terms "healthcare power of attorney" and "healthcare proxy" are used together. In reality, they are one and the same. That being said, you should keep in mind that it is possible to get power of attorney over affairs that aren't related to health care, in which case, "proxy" usually is not the term of choice.
Mental Health PoA forms are generally easy to make, but you or your agent may need legal advice. Locating a legal professional to check your document may take a long time if you attempt to do it by yourself. An easier approach worth consideration is to go through the Rocket Lawyer On Call® attorney network. Rocket Lawyer members have the ability to ask for a document review from an attorney with relevant experience or send additional questions. As always, you can live confidently knowing that Rocket Lawyer is here by your side.
The cost of working with a law firm to make a Mental Health Power of Attorney can total anywhere from $200 to $500, depending on your location. Rocket Lawyer isn't your average Power of Attorney template website. With us, anyone under a Premium membership can take advantage of up to 40% in savings when hiring an Rocket Lawyer network attorney.
Attached to each Power of Attorney form, there's a list of proposed actions to take to finalize your document. You are encouraged to try any or all of the following actions related to your document: editing it, downloading it, printing it out, and/or signing it. Finally, you will need to give a copy of the fully signed document to your agent(s), care providers, and other impacted parties.
The specific requirements and restrictions governing PoA forms are different in each state; however, it is recommended to have your Power of Attorney notarized and/or signed by at least one witness to emphasize the credibility of the document. Finally, as a basic standard, witnesses must not be under the age of 18, and no witness should simultaneously be designated as your PoA agent.
