Forms for Creating an Advance Psychiatric Directive
By: Bazelon Center for Mental Health Law
- A. Directions for using the forms.
- Part I. A statement of your intent in creating
an advance directive for mental health care decisionmaking. This emphasizes
your strong desire that providers respect your right to influence all
decisions about the your care.
- Part II. This form lets you name another person
to make decisions for you if you are determined to be legally incompetent
to make your own choices. Also, your instructions about the circumstances
under which you can change your agent and who should be appointed your
guardian if a court decides to name one.
- Part III. Your instructions about hospitalization
and alternatives to hospitalization, medications, electroconvulsive
therapy (ECT), emergency interventions (including seclusion, restraint
and medication) and experimental studies or drug trials.
- Part IV. Your instructions about who should
be notified immediately if you are admitted to a psychiatric facility,
who should be prohibited from visiting you and who should have temporary
custody of your child(ren).
- Part V. Here you may choose whether or not you
will have the right to suspend or terminate your advance directive while
you are incapacitated, if allowed by the law in your state. The section
includes space for any other instructions about mental health care.
- Part VI. Signature page, on which you and two
witnesses sign the advance directive before a notary, after you have
filled in the blanks and made any changes you wish.
The Bazelon Center doesn't have the capacity to answer individual questions
about the advance directive and its use. For this, you need to contact
your state protection and advocacy
system. However, we welcome your comments and suggestions for improving
these forms.You can e-mail comments
©2001 Bazelon Center for Mental Health Law. Please see www.bazelon.org for updates on this material.