Forms for Creating an Advance Psychiatric Directive

• Directions for using the forms.
• Part I. A statement of your intent in creating an advance directive for mental health care decisionmaking. This emphasizes your strong desire that providers respect your right to influence all decisions about the your care.
• Part II. This form lets you name another person to make decisions for you if you are determined to be legally incompetent to make your own choices. Also, your instructions about the circumstances under which you can change your agent and who should be appointed your guardian if a court decides to name one.
• Part III. Your instructions about hospitalization and alternatives to hospitalization, medications, electroconvulsive therapy (ECT), emergency interventions (including seclusion, restraint and medication) and experimental studies or drug trials.
• Part IV. Your instructions about who should be notified immediately if you are admitted to a psychiatric facility, who should be prohibited from visiting you and who should have temporary custody of your child(ren).
• Part V. Here you may choose whether or not you will have the right to suspend or terminate your advance directive while you are incapacitated, if allowed by the law in your state. The section includes space for any other instructions about mental health care.
• Part VI. Signature page, on which you and two witnesses sign the advance directive before a notary, after you have filled in the blanks and made any changes you wish.

The Bazelon Center doesn't have the capacity to answer individual questions about the advance directive and its use. For this, you need to contact your state protection and advocacy system. However, we welcome your comments and suggestions for improving these forms.You can e-mail comments here.