Advance Directive of (your name)_____________________ for Mental Health Care Decisionmaking

Part II. Appointment Of Agent For Mental Health Care

Make sure you give your agent a copy of all sections of this document.

Statement of Intent to Appoint an Agent:
I, (your name)___________________________________, being of sound mind, authorize a health care agent to make certain decisions on my behalf regarding my mental health treatment when I am incompetent to do so. I intend that those decisions should be made in accordance with my expressed wishes as set forth in this document. If I have not expressed a choice in this document, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.

1. Designation of Mental Health Care Agent
A. I hereby designate and appoint the following person as my agent to make mental health care decisions for me as authorized in this document. This person is to be notified immediately of my admission to a psychiatric facility.
Note: Make sure to list this person in Part IV of your advance directive.

Name: __________________________________________________________________________
Address: _________________________________________________________________________
___________________________________________________________________________________
Day Phone Number ________________________ Night Phone ___________________________

B. Agent’s Acceptance: I hereby accept the designation as agent for
(your name) ______________________________________________________________________

(your agent’s signature)_____________________________________________________________

Designation of Alternate Mental Health Care Agent
If the person named above is unavailable or unable to serve as my agent, I hereby appoint and desire immediate notification of my alternate agent as follows:

Name: _________________________________________________________________________
Address: _______________________________________________________________________
________________________________________________________________________________
Day Phone Number ________________________ Night Phone _________________________

Note: Make sure to list this person in Part IV of your advance directive.

Alternate Agent’s Acceptance: I hereby accept the designation as alternate agent for
(your name)______________________________________________________________________

(Your agent’s signature)_____________________________________________________________

The following paragraphs will apply when you appoint an agent.

2. Authority Granted to My Agent
Initial if you agree with a statement; leave blank if you do not.

A. ________ If I become incapable of giving consent to mental health care treatment, I hereby grant to my agent full power and authority to make mental health care decisions for me, including the right to consent, refuse consent, or withdraw consent to any mental health care, treatment, service or procedure, consistent with any instructions and/or limitations I have set forth in this advance directive. If I have not expressed a choice in this advance directive, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.

B._________ Having named an agent to act on my behalf, I do, however, wish to be able to discharge or change the person who is to be my agent if that agent is instrumental in the process of initiating or extending any period of psychiatric treatment against my will. My ability to revoke or change agents in this circumstance shall be in effect even while I am incompetent or incapacitated, if allowed by law. Even if I choose to discharge or replace my agent, all other provisions of this advance directive shall remain in effect and shall only be revokable or changeable by me at a time when I am considered competent and capable of making informed health care decisions.

3. When Spouse Is Agent and If There Has Been a Legal Separation, Annulment, or Dissolution of the Marriage
Initial if you agree with this statement; leave blank if you do not.

__________ I desire the person I have named as my agent, who is now my spouse, to remain as my agent even if we become legally separated or our marriage is dissolved.

4. My Preference as to a Court-Appointed Guardian
In the event a court decides to appoint a guardian who will make decisions regarding my mental health treatment, I desire the following person to be appointed:

Name:_________________________________________ Relationship:_________________________
Address: ____________________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Day phone: ______________________________ Evening Phone: ____________________________

5. Powers of a Guardian
The appointment of a guardian of my estate or my person or any other decisionmaker shall not give the guardian or decisionmaker the power to revoke, suspend, or terminate this directive or the powers of my agent, except as specifically required by law.

Make sure you give your agent a copy of all sections of this document. 

Go to Part III of the Advance Directive.

© Copyright 1998 Judge David L. Bazelon Center for Mental Health Law. Reproduction for personal use or for training is permitted.