66-613. FORM OF DECLARATION. A declaration for mental health treatment shall contain the following language, or language that is substantially similar.

NOTICE TO PERSON 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:

(1) This document allows you to make decisions in advance about three (3) types of mental health treatment: psychotropic medication, electroconvulsive therapy, and short-term (up to seventeen (17) days) admission to a treatment facility. The instructions that you include in this declaration will be followed only if a court, two (2) physicians that include a psychiatrist, or a physician and a professional mental health clinician believe that you are incapable of making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments.

(2) You may also appoint a person as your agent to make these treatment decisions for you if you become incapable. The person you appoint has a duty to act consistent with your desires as stated in this document or, if your desires are not stated or otherwise made known to the agent, 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. The person also has the right to withdraw from acting as your agent at any time.

(3) This document will continue in effect until revoked. You have the right to revoke this document in whole or in part at any time you have not been determined to be incapable. YOU MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED INCAPABLE BY A COURT, TWO (2) PHYSICIANS THAT INCLUDE A PSYCHIATRIST, OR A PHYSICIAN AND A PROFESSIONAL MENTAL HEALTH CLINICIAN. A revocation is effective when it is communicated to your attending physician or other provider.

(4) 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 (2) qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature.

History:

[66-613, added 1998, ch. 81, sec. 1, p. 290.]