Declaration For Mental Health Treatment

I,________________________________________, being an adult of sound mind, wilfully and voluntarily make this declaration for mental health treatment to be followed if it is determined by a court that my ability to understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment, is impaired to such an extent that I lack the capacity to make mental health treatment decisions. "Mental health treatment", means electroconvulsive or other convulsive treatment, treatment of mental illness with psychoactive medication, and preferences regarding emergency mental health treatment. (Optional Paragraph) I understand that I may become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder. These symptoms may include:
 
___________________________________________________________________
 
Psychoactive Medications
If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychoactive medications are as follows:
 
_____I consent to the administration of the following medications:

___________________________________________________________________


_____I do not consent to the administration of the following medications:

___________________________________________________________________



_____I consent to the administration of a federal Food and Drug Administration approved medication that was only approved and in existence after my declaration and that is considered in the same class of psychoactive medications as stated below:

_____________________________________________________________________

_____________________________________________________________________



Conditions or limitations: __________________________________________________

_____________________________________________________________________

_____________________________________________________________________



Convulsive Treatment
If I become incapable of giving or withholding informed consent for mental health treatment, my
wishes regarding convulsive treatment are as follows:


_____I consent to the administration of convulsive treatment.



_____I do not consent to the administration of convulsive treatment.



Conditions or limitations: ___________________________________________________
 
______________________________________________________________________
 
______________________________________________________________________

 
Preferences For Emergency Treatment

In an emergency, I prefer the following treatment FIRST (circle one)
Restraint Seclusion Medication.
In an emergency, I prefer the following treatment SECOND (circle one)
Restraint Seclusion Medication.
In an emergency, I prefer the following treatment THIRD (circle one) 
Restraint Seclusion Medication.

_____I prefer a male/female to administer restraint, seclusion, and/or medications.
 
Options for treatment prior to use of restraint, seclusion, and or medications:
 
_______________________________________________________________________

Conditions or limitations:_____________________________________________________

_______________________________________________________________________

Additional Preferences or Instructions:
 
_______________________________________________________________________



_______________________________________________________________________


Conditions or limitations:

______________________________________________________________________

______________________________________________________________________

Signature of Principal/Date: _________________________________________________