|
Advance Directive of (your name)_____________________ for
Mental Health Care Decisionmaking
Part VI. Signature Page
By signing here I indicate that I understand the purpose and effect
of this document.
|
_________________________________________________
Your Signature
|
_________________________________________
Date
|
The directive above was signed and declared by the "Declarant," (your
name)____________________
___________________ , to be his/her mental health care advance directive,
in our presence who, at his/her request, have signed names below as witness.
We declare that, at the time of the execution of this instrument, the
Declarant, according to our best knowledge and belief, was of sound mind
and under no constraint or undue influence. We further declare that none
of us is: 1) a physician; 2) the Declarant's physician or an employee
of the Declarant's physician; 3) an employee or a patient of any residential
health care facility in which the Declarant is a patient; 4) designated
as agent or alternate under this document; or 5) a beneficiary or creditor
of the estate of the Declarant.
Dated at _____________________________________________ (county, state),
this ___________________ day of ___________________, 19____.
|
Witness Signatures
|
|
Witness 1:
____________________________________
Signature of Witness 1
____________________________________
Name of Witness 1 (printed)
____________________________________
Home address of Witness 1
____________________________________
City, State, Zip Code of Witness 1
|
Witness 2:
____________________________________
Signature of Witness 2
____________________________________
Name of Witness 2 (printed)
____________________________________
Home address of Witness 2
____________________________________
City, State, Zip Code of Witness 2
|
|
(for use by the notary):
State of_________________, County of ___________________________
Subscribed and sworn to or affirmed before me by the Declarant,
_______________________________________________,
and (names of witnesses)
________________________________________________ and
________________________________________________,
witnesses, as the voluntary act and deed of the Declarant, this
___________ day of ___________, _____________.
My commission expires:
__________________________________________________________
__________________________________________________________
Notary Public
|
Record of Psychiatric Advance Directive
Keep this form and give a copy to your agent, if you have appointed
one.
|
|
_____________________________________
My name
|
_____________________________________
My health care agent's name
|
|
_____________________________________
My address
|
_____________________________________
My health care agent's address
|
|
_____________________________________
|
_____________________________________
|
|
_____________________________________
My date of birth
|
_____________________________________
My health care agent's telephone number(s)
|
|
I have given copies of this form to:
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
|
_____________________________________
Name
|
____________________________________
Address or phone
|
© Copyright 1998 Judge David L. Bazelon Center for Mental Health
Law. Reproduction for personal use or for training is permitted.
|
