1.   My Choice of Treatment Facility and Preferences for Alternatives to Hospitalization If 24-Hour Care Is Deemed Medically Necessary for My Safety and Well-Being

A. _____ In the event my psychiatric condition is serious enough to require 24-hour care and I have no physical conditions that require immediate access to emergency medical care, I would prefer to receive this care in programs/facilities designed as alternatives to psychiatric hospitalizations.

A1. _____ I would prefer to receive 24-hour
care at the following programs/facilities:

 
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B._____ In the event I am to be admitted to a hospital for 24-hour care, I would prefer to receive care at the following hospitals:

____________________________________

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C. _____ I do not wish to be committed to the following hospitals or programs/facilities for psychiatric care for the reasons I have listed:

Facility's Name:__________________________________________________________

Reason: _________________________________________________________________

Facility's Name: _________________________________________________________

Reason:_________________________________________________________________

Facility's Name: _________________________________________________________

Reason:_________________________________________________________________

2. My Preferences Regarding Emergency Interventions

If, during an admission or commitment to a mental health treatment facility, it is determined that I am engaging in behavior that requires an emergency intervention (e.g., seclusion and/or physical restraint and/or medication), my wishes regarding which form of emergency interventions should be made are as follows. I prefer these interventions in the following order:

Fill in numbers, giving 1 to your first choice, 2 to your second, and so on until each has a number. If an intervention you prefer is not listed, write it in after "other" and give it a number as well.

 
_____ seclusion

_____ physical restraints

_____ seclusion and physical restraint (combined)

_____ medication by injection

_____ medication in pill form

_____ liquid medication

_____ other:________________________

____________________________________

____________________________________

 
Reasons for my preferences:

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Initial this paragraph if you agree; leave blank if you do not agree.

__________ In the event that my attending physician decides to use medication for rapid tranquilization in response to an emergency situation after due consideration of my preferences for emergency treatments stated above, I expect the choice of medication to reflect any preferences I have expressed in this section and in Section 3. The preferences I express in this section regarding medication in emergency situations do not constitute consent to use of the medication for non-emergency treatment.

3. My Preferences About the Physicians Who Will Treat Me if I Am Hospitalized.

Put your initials after the letter and complete if you wish either or both paragraphs to apply.

A. __________My choice of treating physician is:

Dr. _______________________________

Phone number _____________________

OR

Dr. ______________________________

Phone number ____________________

OR

Dr. _____________________________

Phone number ___________________

B. __________I do not wish to be treated by the following, for the reasons stated:

Dr. ______________________________________

Reason: __________________________________

_________________________________________

_________________________________________

Dr. ______________________________________

Reason:___________________________________

_________________________________________

_________________________________________

4. My Preferences Regarding Medications for Psychiatric Treatment

In this section, you may choose any of the paragraphs A-G that you wish to apply. Be sure to initial those you choose.

If it is determined that I am not legally competent to consent to or to refuse medications relating to my mental health treatment, my wishes are as follows:

 
A. _____ I consent to the medications agreed to by my agent, after consultation with my treating physician and any other individuals my agent may think appropriate, with the reservations, if any, described in (D) below.

 
B._____ I consent to and authorize my agent to consent to the administration of:

 
C._____ I consent to the medications deemed appropriate by Dr._________________________,

whose address and phone number are: ______________________________________________

______________________________________________________________________________

 
D. _____ I specifically do not consent and I do not authorize my agent to consent to the administration of the following medications or their respective brand-name, trade-name or generic equivalents:

 
E._____ I am willing to take the medications excluded in (D) above if my only reason for excluding them is their side effects and the dosage can be adjusted to eliminate those side effects.

 
F. ____ I am concerned about the side effects of medications and do not consent or authorize my agent to consent to any medication that has any of the side effects I have checked below at a 1% or greater level of incidence (check all that apply).

 
G._____ I have the following other preferences about psychiatric medications:

______________________________________________________________________________

______________________________________________________________________________

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5. My Preferences Regarding Electroconvulsive Therapy (ECT or Shock Treatment)

If it is determined that I am not legally capable of consenting to or refusing electroconvulsive therapy, my wishes regarding electroconvulsive therapy are as follows:

Initial A or B; if you check B, you must also initial B1, B2 or B3:

 
A._____ I do not consent to administration of electroconvulsive therapy.

 
B._____ I consent, and authorize my agent to consent, to the administration of electroconvulsive therapy, but only:

B1. _____with the number of treatments that the attending psychiatrist deems appropriate;
OR
B2. _____ with the number of treatments that Dr. __________________________ deems appropriate. Phone number and address of doctor:
_________________________________
_________________________________
_________________________________
OR
B3. _____for no more than the following number of ECT treatments: __________

 
C. _____ Other instructions and wishes regarding the administration of electroconvulsive therapy:

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6. Consent for Experimental Studies or Drug Trials

Initial one of the following paragraphs.

 
A. _____ I do not wish to participate in experimental drug studies or drug trials.

B. _____ I hereby consent to my participation in experimental drug studies or drug trials.

 
C. _____ I authorize my agent to consent to my participation in experimental drug studies if my agent, after consultation with my treating physician and any other individuals my agent may think appropriate, determines that the potential benefits to me outweigh the possible risks of my participation and that other, non-experimental interventions are not likely to provide effective treatment.