1. Who Should Be Notified Immediately of My Admission to a Psychiatric Facility

If I am incompetent, I desire staff to notify the following individuals immediately that I have been admitted to a psychiatric facility:

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

2. Who Should Be Prohibited from Visiting Me

I do not wish the following people to visit me while I am receiving care in a psychiatric facility:

Name

Relationship

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

3. My Preferences for Care & Temporary Custody of My Children

In the event that I am unable to care for my child(ren), I want the following person as my first choice to care for and have temporary custody of my child(ren):

Name: _____________________________________ Relationship: ______________

Address: _______________________________________________________________

City, State, Zip:________________________________________________________

Phone number: (Day) __________________________ (Evening)__________________

In the event that the person named above is unable to care for and have temporary custody of my child(ren), I desire one of the following people to serve in that capacity.

My Second Choice

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

My Third Choice

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________