A. A declaration stating the mental health treatment wishes of the declarant executed in accordance with the provisions of this act shall be substantially in the form provided by subsection E of this section.

B. A declarant may designate a capable person eighteen (18) years of age or older to act as attorney-in-fact to make mental health treatment decisions. An alternative attorney-in-fact may also be designated to act as attorney-in-fact if the original attorney-in-fact is unable or unwilling to act at any time. An appointment of an attorney-in-fact shall be substantially in the form provided by subsection E of this section.

C. An attorney-in-fact who has accepted the appointment in writing shall have authority to make decisions, in consultation with the attending physician or psychologist, about mental health treatment on behalf of the declarant only when the declarant is certified as incapable and to require mental health treatment as provided by Section 10 of this act.

1. These decisions shall be consistent with any wishes or instructions the declarant has expressed in the declaration. If the wishes or instructions of the declarant are not expressed, the attorney-in-fact shall act in what the attorney-in-fact believes to be in the best interest of the declarant.

2. The attorney-in-fact may consent to inpatient mental health treatment on behalf of the declarant if so authorized in the advance directive for mental health treatment.

D. An attorney-in-fact may withdraw by giving notice to the declarant. If a declarant is incapable, the attorney-in-fact may withdraw by giving notice to the named alternative attorney-in-fact if any, and if none then to the attending physician or provider. The attending physician or provider shall note the withdrawal of the last named attorney-in-fact as part of the declarant's medical record.

E. An advance directive for mental health treatment shall be notarized and shall be in substantially the following form:

ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT

I, _____________________, being of sound mind and eighteen (18) years of age or older, willfully and voluntarily make known my wishes about mental health treatment, by my instructions to others through my advance directive for mental health treatment, or by my appointment of an attorney-in-fact, or both. I thus do hereby declare:

I. DECLARATION FOR MENTAL HEALTH TREATMENT

If my attending physician or psychologist and another physician or psychologist determine that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment and that mental health treatment is necessary, I direct my attending physician or psychologist and other health care providers, pursuant to the Advance Directives for Mental Health Treatment Act, to provide the mental health treatment I have indicated below by my signature.

I understand that "mental health treatment" means convulsive treatment, treatment with psychoactive medication, and admission to and retention in a health care facility for a period up to twenty-eight (28) days.

I direct the following concerning my mental health care:___________________________________________________

________________________________________________________________

I further state that this document and the information contained in it may be released to any requesting licensed mental health professional.

_______________________________________________

Declarant's SignatureDate

_______________________________________________

Witness 1Date

_______________________________________________

Witness 2Date

II. APPOINTMENT OF ATTORNEY-IN-FACT

If my attending physician or psychologist and another physician or psychologist determine that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment and that mental health treatment is necessary, I direct my attending physician or psychologist and other health care providers, pursuant to the Advance Directives for Mental Health Treatment Act, to follow the instructions of my attorney-in-fact.

I hereby appoint:

NAME _____________________________________

ADDRESS __________________________________

TELEPHONE #_______________________________

to act as my attorney-in-fact to make decisions regarding my mental health treatment if I become incapable of giving or withholding informed consent for that treatment.

If the person named above refuses or is unable to act on my behalf, or if I revoke that person's authority to act as my attorney-in-fact, I authorize the following person to act as my attorney-in-fact:

NAME ______________________________________

ADDRESS ___________________________________

TELEPHONE #________________________________

My attorney-in-fact is authorized to make decisions which are consistent with the wishes I have expressed in my declaration. If my wishes are not expressed, my attorney-in-fact is to act in what he or she believes to be my best interest.

_______________________________________

(Signature of Declarant/Date)

III. CONFLICTING PROVISION

I understand that if I have completed both a declaration and have appointed an attorney-in-fact and if there is a conflict between my attorney-in-fact's decision and my declaration, my declaration shall take precedence unless I indicate otherwise.

____________________ ___________ (signature)

IV. OTHER PROVISIONS

a. In the absence of my ability to give directions regarding my mental health treatment, it is my intention that this advance directive for mental health treatment shall be honored by my family and physicians or psychologists as the expression of my legal right to consent or to refuse to consent to mental health treatment.

b. This advance directive for mental health treatment shall be in effect until it is revoked.

c. I understand that I may revoke this advance directive for mental health treatment at any time.

d. I understand and agree that if I have any prior advance directives for mental health treatment, and if I sign this advance directive for mental health treatment, my prior advance directives for mental health treatment are revoked.

e. I understand the full importance of this advance directive for mental health treatment and I am emotionally and mentally competent to make this advance directive for mental health treatment.

Signed this _____ day of__________, 19 __

___________________________________

(Signature)

___________________________________

City, County and State of Residence

This advance directive was signed in my presence.

___________________________________

(Signature of Witness)

___________________________________

(Address)

___________________________________

(Signature of Witness)

___________________________________

(Address)

Added by Laws 1995, c. 251, § 6, eff. Nov. 1, 1995.