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How to Fill Out a Declaration for Mental Health Treatment Form

First, you must be mentally competent to make a declaration. Second, you need an official form to fill out. You cannot make a legal Declaration without one. The form​ is official, and will be valid if it is correctly filled out, signed and witnessed.

To be valid the effective form must:

  1. Contain your name.
  2. Be signed and dated by you.
  3. Be signed and dated by two witnesses who are present either when you signed or when you acknowledged that you signed the Declaration. They must believe you are mentally competent at the time you signed the form.
  4. Contain your instructions about mental health treatment.

The process

Follow these steps to make a legally valid Declaration for Mental Health Treatment:

Step 1- Name

Print or type your name legibly on the first line of the form after "I,".

Step 2- Symptoms

If you think it is important for a doctor or other mental health treatment provider to know about the symptoms you experience when you go into crisis, you can include these symptoms on the lines provided after the second paragraph. This could be important for a provider to understand your condition.

This information is NOT required. A Declaration will be valid whether or not you put anything on these lines.

Step 3- Psychoactive Medication

The next part of the form, which is entitled "PSYCHOACTIVE MEDICATION," is where you put your instructions about medicine. If you want specific instructions to be followed by a provider or your attorney-in-fact, "your representative", (if you choose to appoint one), those instructions must be put here.

If you want to give consent for certain types of drugs, put a check mark on the line next to If you want to give consent for certain types of drugs, put a check mark on the line next to "I consent to the administration of the following medications."

If you want to give consent to any drug the doctor may recommend, write in: If you want to give consent to any drug the doctor may recommend, write in: "Any that my doctor recommends."

If you want to limit your consent in any way, such as maximum dosage, or you want certain information considered such as allergies you may have, you may add these instructions or information on the lines provided at the bottom of the page for If you want to limit your consent in any way, such as maximum dosage, or you want certain information considered such as allergies you may have, you may add these instructions or information on the lines provided at the bottom of the page for "Conditions or limitations."

If you have also appointed an attorney-in-fact, If you have also appointed an attorney-in-fact, "your representative"

If you want to specifically refuse any drug, put a check mark on the line next to If you want to specifically refuse any drug, put a check mark on the line next to "I do not consent to the administration of the following medications."

If you want to refuse all drugs, write in: If you want to refuse all drugs, write in: "All medications."

If you wish to explain your refusal of consent, this can be written on the lines at the bottom of the page for "Conditions or limitations."

Step 4- Convulsive Treatment

In the next part of the form, entitled "CONVULSIVE TREATMENT," you may give or withhold consent for convulsive treatment. This includes "shock treatment" or "ECT" (Electroconvulsive treatment).

If you want to make a decision in advance about this type of treatment, place a check mark by the sentence that expresses your desires. You can add additional information or instructions on the lines following "Conditions or limitations." These might include a limitation on the number or type of treatments you consent to or a direction to consult your attorney-in-fact, "your representative", for the decisions.

If you state that you consent to convulsive treatment, you will not necessarily receive it. A doctor must first recommend the treatment for your condition. Your consent does not give a doctor the right to make improper recommendations.

Step 5- Admission and Retention in Facility

In the part of the form entitled "ADMISSION TO AND RETENTION IN FACILITY," you may give or withhold consent to be kept in a health care facility for mental health treatment for up to 17 days. To do this, place a check mark in front of the statement that expresses your wishes.

If you wish to consent to inpatient treatment, but for less than 17 days or wish to specify or rule out facilities you agree to be admitted to, write these instructions on the lines at the bottom of this section after If you wish to consent to inpatient treatment, but for less than 17 days or wish to specify or rule out facilities you agree to be admitted to, write these instructions on the lines at the bottom of this section after "Conditions or limitations.

Step 6- Additional References or Instructions

If there is any other information or instructions that your doctor, provider or attorney-in-fact should know, write them in the section entitled "ADDITIONAL REFERENCES OR INSTRUCTIONS.

Step 7- Attorney-in-Fact

If you wish to appoint another person to make mental health treatment decisions for you, write the person's name and telephone number in the section entitled "ATTORNEY-IN-FACT." You can also appoint a second person to act as a back-up should your first choice become unable to serve.

Anyone who you appoint as an attorney-in-fact must agree to serve in that capacity. That person must sign the page of this form entitled Anyone who you appoint as an attorney-in-fact must agree to serve in that capacity. That person must sign the page of this form entitled "ACCEPTANCE OF APPOINTMENT AS ATTORNEY-IN-FACT.

Step 8- Your Signature

Sign and date the form at the bottom of page 5. Do this in front of two witnesses. Your signature must appear in this place for any part of the directive to be effective.

Step 9- Affirmation of Witnesses

Have your two witnesses sign the form on page 6 in the section headed "AFFIRMATION OF WITNESSES.

Some people CANNOT act as witnesses. People who CANNOT act as witnesses include:

  • Your attorney-in-fact or alternate attorney-in-fact, i.e. your personal representative. Anyone you appoint in Step 7 cannot be a witness.
  • A physician or mental health service provider who is treating you, or a relative of a person who is treating you. Your case manager, any doctor who is treating you while you're in the hospital, your counselor private psychiatrist cannot serve as witnesses.
  • The owner or operator of the facility where you live, or a relative of one of these people. For example, if you live in a group home, the owner or staff of the group home cannot serve as witnesses. The same is true of staff at nursing homes, foster homes, board and care homes, etc.
  • If you signed the form when the witnesses were not present, they can still sign as witnesses if you tell them that the signature on the form is yours.

When the witnesses sign the form they acknowledge that you signed the Declaration, and that they believe you were mentally competentat the time you signed the form.

Step 10- Others' Signatures

If you have appointed an attorney-in-fact, "your representative make sure that your representative has signed the acceptance of appointment.

Although the form doesn't say so, some people cannot act as your attorney-in-fact. People who CANNOT be your attorney-in-fact are:

  • Your doctor, mental health service provider, or an employee of your doctor or provider, unless you are related to that person.
  • An owner, operator, or employee of a health care facility where you live or are a patient, unless you are related to that person.

If you do not appoint an attorney-in-fact or if the person you appoint does not accept appointment or is disqualified from serving, all of the other instructions in the Directive are still valid.

Step 11- Hand Out Copies

Make sure that you give copies of the completed form to any doctor, provider, or facility from which you expect to need treatment. If you have appointed an attorney-in-fact, make sure that this person also has a copy. Your instructions cannot be followed if they are not know to exist.​​​

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