Advance Directive For Mental Health Treatment printable pdf download

Advance Directive For Mental Health Treatment

Advance Directive for Mental Health Treatment

This document is to be used as an example only. Please contact your state's

Protection and Advocacy

Program, a lawyer, paralegal, or advocate

to create a legally binding document.

My Name: _______________________________________________________

Symptoms that tell me I may not be capable of making decisions for

myself:

____________________________________________________________

I appoint the following person to act as my representative to make

decisions about my mental health care if I become incapable:

Name: __________________________________________________________

Address: ________________________________________________________

________________________________________________________

Phone: __________________________________________________________

If the above person is not available or refuses to act on my behalf, the

following person can act on my behalf:

Name: __________________________________________________________

Address: ________________________________________________________

________________________________________________________

Phone: __________________________________________________________

Advance Directive For Mental Health Treatment