Example of an Advance Directive

ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT

I, ____________________, willfully and voluntarily execute this advance directive for mental health treatment. I want the instructions in this advance directive to be followed as described below.

Designated Surrogate

_____ I am naming a surrogate to see that my instructions for mental health treatment 
are carried out.
I designate ____________________ to act as my surrogate.  
If this person withdraws or is unwilling to act on my behalf, or if I revoke that 
person's authority to act as my surrogate, 
I designate ____________________ to act as my alternate surrogate.
The person acting as my surrogate is authorized to act in accordance with the content 
of this advance directive and may override the advance directive if, and only if, there 
is substantial medical evidence that failing to do so would result in harm to me.  
If my instructions and preferences are not stated in the advance directive, the 
surrogate may act in good faith in making treatment decisions in the manner in 
which the surrogate believes I would act.


_____ I am not naming a surrogate to see that my instructions for mental health 
treatment are carried out.


If I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are 
unwilling to act on my behalf, or if I revoke their authority to act, then the health care 
provider and health care facility may proceed to render treatment in accordance with 
my instructions as described here and in accordance with 
standards for mental and physical health care.

Psychotropic Medication Provisions

I may indicate below any refusals of treatment with specific psychotropic medications, 
not to include an entire class of medications, due to factors that may include but are 
not limited to lack of efficacy, known drug sensitivity, or experience of adverse reaction:

_____________I specifically do not consent and do not authorize my surrogate to consent 
to the administration of the following medications or their respective brand-name or 
generic equivalents for the reasons given:

Specific psychotropic medication	Reason for refusal

I may list below any specific psychotropic medications that I would be willing to have administered to me if additional medications become necessary:

Specific psychotropic medications:

__________________________

Electroconvulsive Therapy Provisions

Below are my instructions regarding electroconvulsive therapy (ECT):

_____ I consent to electroconvulsive therapy (ECT) if it is deemed clinically
appropriate to treat my condition.

_____ I do not consent to electroconvulsive therapy (ECT).

Preferred Procedures for Emergency Interventions

I may state preferences for procedures for emergency interventions to be used when necessary for my protection or the protection of others. I understand that I am requesting consideration of my preferences for procedures for emergency interventions but that my surrogate, my health care provider, and the health care facility where I am a patient are not subject to civil liability for not abiding by these preferences. I understand that in the case of possible harm to myself or others, my health care provider or the health care facility may need to use procedures that override my stated preferences. If during an admission or while a patient in a health care facility, it is determined that I am engaging in behavior that requires emergency intervention, my preferences regarding the procedures to be used during an emergency intervention and the order that I prefer the interventions to be used are as follows:

Intervention	Order of Preference	Reason for preference
Seclusion
Physical restraints
Seclusion & physical restraint combined
Medication by injection
Medication in pill form
Liquid medication
Other
Other

Signed this _____ day of ____________________, 20_____

Signature of grantor: _______________________________________

Address of grantor:
________________________________________

________________________________________
In my presence, the grantor voluntarily dated and signed this writing or directed it to be dated and signed. I am not the grantor's current health care provider, a relative of the current health care provider, or an owner, operator, employee or relative of an owner or operator of a health facility in which the grantor is a client or resident.

Signature of witness: _____________________________________

Surrogate contact information (if designated):

Name: ___________________________

Address: _________________________ ________________________________

Telephone: _______________________

Signed this ____ day of_____________, 20_____.

Signature of surrogate: _________________________________

Alternate surrogate contact information (if designated):