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Mental Health Advance Directive (Psychiatric Advance Directive)

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MENTAL HEALTH ADVANCE DIRECTIVE

(Psychiatric Advance Directive)

IMPORTANT NOTICE

This Mental Health Advance Directive (MHAD), also known as a Psychiatric Advance Directive (PAD), allows you to document your preferences for mental health treatment in advance, to be followed if you become unable to make decisions for yourself during a mental health crisis.

This document becomes effective when:

A qualified healthcare provider determines you lack capacity to make mental health treatment decisions, OR
The specific triggering conditions you identify below occur

This document does NOT:

Override involuntary commitment laws in emergency situations
Authorize illegal treatments
Require providers to provide treatments outside standard of care

PART I: DECLARANT INFORMATION

Section A: Personal Information

Full Legal Name: __________________________________________

Other Names Used: _________________________________________

Date of Birth: ____________________________________________

Social Security Number (last 4 digits): ____________________

Current Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

Section B: Emergency Contacts

Primary Emergency Contact:

Name: _________________________________________________________

Relationship: _________________________________________________

Phone: ________________________________________________________

Email: ________________________________________________________

Address: ______________________________________________________

Secondary Emergency Contact:

Name: _________________________________________________________

Relationship: _________________________________________________

Phone: ________________________________________________________

Email: ________________________________________________________

Address: ______________________________________________________

PART II: MENTAL HEALTH CARE AGENT (PROXY)

Section A: Appointment of Agent

☐ I DO appoint a mental health care agent to make decisions on my behalf

☐ I DO NOT appoint an agent; I want my written instructions followed

If appointing an agent:

Primary Agent:

Name: _________________________________________________________

Relationship: _________________________________________________

Address: ______________________________________________________

Phone (primary): ______________________________________________

Phone (alternate): ____________________________________________

Email: ________________________________________________________

Alternate Agent (if primary is unavailable or unwilling):

Name: _________________________________________________________

Relationship: _________________________________________________

Address: ______________________________________________________

Phone (primary): ______________________________________________

Phone (alternate): ____________________________________________

Email: ________________________________________________________

Section B: Agent's Authority

My agent is authorized to make decisions regarding (check all that apply):

☐ Consent to or refuse psychiatric hospitalization

☐ Consent to or refuse specific medications

☐ Consent to or refuse electroconvulsive therapy (ECT)

☐ Consent to or refuse psychotherapy/counseling

☐ Select mental health care providers and facilities

☐ Access my mental health records

☐ Communicate with family members about my condition

☐ Make decisions about experimental treatments

☐ Decisions regarding seclusion and restraint

☐ Decisions regarding my living situation during treatment

☐ Decisions regarding my employment/finances during crisis

☐ Other: _____________________________________________________

Section C: Limitations on Agent's Authority

My agent is NOT authorized to:

☐ Consent to ECT without my prior written consent in this document

☐ Consent to experimental treatments

☐ Consent to psychosurgery

☐ Authorize treatments I have specifically refused in this document

☐ Other limitations: __________________________________________

_______________________________________________________________

Section D: Instructions to Agent

Special instructions for my agent:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PART III: MENTAL HEALTH TREATMENT PREFERENCES

Section A: Current Mental Health Information

Current Diagnosis(es):
_______________________________________________________________
_______________________________________________________________

Current Treatment Provider(s):

Psychiatrist: _________________________________________________
Phone: ________________________________________________________

Therapist/Counselor: __________________________________________
Phone: ________________________________________________________

Primary Care Physician: _______________________________________
Phone: ________________________________________________________

Other Provider: _______________________________________________
Phone: ________________________________________________________

Current Medications:

Medication	Dosage	Frequency	Prescriber
__________________	__________	__________	__________________
__________________	__________	__________	__________________
__________________	__________	__________	__________________
__________________	__________	__________	__________________
__________________	__________	__________	__________________

Section B: Warning Signs and Triggers

Signs that I may be experiencing a mental health crisis:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Known triggers for my mental health crises:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Behaviors that indicate I need immediate intervention:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PART IV: MEDICATION PREFERENCES

Section A: Medications That Have Helped

The following medications have been effective for me in the past:

Medication	Dosage	Condition Treated	Notes
__________________	__________	__________________	__________________
__________________	__________	__________________	__________________
__________________	__________	__________________	__________________
__________________	__________	__________________	__________________

Section B: Medications I Refuse

☐ I consent to all psychiatric medications deemed appropriate by my treatment team

☐ I refuse the following medications (and provide reasons if desired):

Medication	Reason for Refusal
__________________	_____________________________________
__________________	_____________________________________
__________________	_____________________________________
__________________	_____________________________________

Section C: Medications I Have Had Adverse Reactions To

Medication	Adverse Reaction
__________________	_____________________________________
__________________	_____________________________________
__________________	_____________________________________

Section D: Medication Allergies

Medication/Class	Type of Allergic Reaction
__________________	_____________________________________
__________________	_____________________________________

Section E: Preferences for Medication Administration

☐ I prefer oral medications when possible

☐ I consent to injectable medications if I refuse oral medications

☐ I consent to injectable medications only in emergencies

☐ I refuse all injectable medications except in life-threatening emergencies

☐ Other preferences: __________________________________________

PART V: TREATMENT PREFERENCES

Section A: Hospitalization Preferences

Preferred Facility(ies):

Facility Name: _____________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________
Reason for preference: _____________________________________
Facility Name: _____________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________
Reason for preference: _____________________________________

Facilities I Wish to Avoid:

Facility Name: _____________________________________________
Reason: ____________________________________________________
Facility Name: _____________________________________________
Reason: ____________________________________________________

Section B: Electroconvulsive Therapy (ECT)

☐ I consent to ECT if my treatment team determines it is necessary

☐ I consent to ECT only under the following circumstances:
___________________________________________________________
___________________________________________________________

☐ I refuse ECT under any circumstances

☐ I want my agent to make this decision based on circumstances

If I consent to ECT, my preferences are:

☐ Bilateral electrode placement

☐ Unilateral electrode placement

☐ No preference - provider discretion

Number of treatments I consent to: ☐ Up to ___ ☐ As recommended

Section C: Psychotherapy Preferences

☐ I consent to psychotherapy/counseling during crisis

Preferred types of therapy:
☐ Individual therapy
☐ Group therapy
☐ Family therapy
☐ Cognitive Behavioral Therapy (CBT)
☐ Dialectical Behavior Therapy (DBT)
☐ Other: _____________________________________________________

Therapist preferences:
☐ No gender preference
☐ Prefer female therapist
☐ Prefer male therapist
☐ Prefer therapist of specific background: _____________________

Section D: Other Treatments

Treatments I consent to:
☐ Transcranial Magnetic Stimulation (TMS)
☐ Ketamine/Esketamine therapy
☐ Light therapy
☐ Peer support services
☐ Occupational therapy
☐ Art/Music therapy
☐ Spiritual/Religious counseling
☐ Other: _____________________________________________________

Treatments I refuse:
☐ ____________________________________________________________
☐ ____________________________________________________________
☐ ____________________________________________________________

Section E: Seclusion and Restraint

☐ I understand seclusion and restraint may be used only in emergencies to prevent imminent harm

My preferences regarding de-escalation:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

If seclusion or restraint becomes necessary:
☐ I prefer seclusion over physical restraint
☐ I prefer physical restraint over seclusion
☐ I prefer chemical restraint (medication) over physical restraint
☐ No preference - provider discretion based on circumstances

PART VI: PRACTICAL MATTERS DURING INCAPACITY

Section A: Persons to Notify

Please notify the following persons if I am hospitalized:

Name	Relationship	Phone	Notify?
__________________	__________________	__________________	☐ Yes ☐ No
__________________	__________________	__________________	☐ Yes ☐ No
__________________	__________________	__________________	☐ Yes ☐ No

Persons who should NOT be notified or permitted to visit:

Name	Relationship	Reason
__________________	__________________	__________________
__________________	__________________	__________________

Section B: Dependents and Pets

Children or other dependents requiring care:

Name: _________________________ Age: _____ Contact for care: _______________

Pets requiring care:

Type/Name: _____________________ Contact for care: _______________________

Special instructions: _________________________________________

Section C: Employment

Employer: _________________________________________________

Supervisor: _______________________________________________

Phone: ____________________________________________________

Instructions regarding employer notification:
☐ Do not notify my employer under any circumstances
☐ Notify my employer that I am ill (without details)
☐ My agent may notify my employer as needed
☐ Other: _____________________________________________________

Section D: Financial Responsibilities

Bills that must be paid during my incapacity:

Payee	Account Number	Amount	Due Date
__________________	__________________	________	________
__________________	__________________	________	________
__________________	__________________	________	________

Person authorized to handle finances: _______________________

Section E: Housing

Current living situation:
☐ Own home/apartment
☐ Rent
☐ Live with family
☐ Other: _____________________________________________________

Instructions for my residence during hospitalization:
_______________________________________________________________
_______________________________________________________________

PART VII: ADDITIONAL INSTRUCTIONS

Section A: Cultural/Religious/Spiritual Preferences

Religious/Spiritual affiliation: ___________________________

Cultural considerations for my treatment:
_______________________________________________________________
_______________________________________________________________

I would like access to:
☐ Clergy/spiritual advisor
☐ Religious texts: ___________________________________________
☐ Dietary accommodations: _____________________________________
☐ Other: _____________________________________________________

Section B: Things That Help Me During Crisis

Things that typically help me feel better:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Things to avoid that make my condition worse:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Section C: Any Additional Instructions

PART VIII: ACTIVATION AND REVOCATION

Section A: When This Directive Becomes Effective

This directive becomes effective when:

☐ A licensed physician or qualified mental health professional determines that I lack capacity to make mental health treatment decisions

☐ Two licensed healthcare providers determine that I lack capacity

☐ I voluntarily activate it by notifying my treatment provider

☐ Other conditions: ___________________________________________

Section B: Revocation

☐ I understand I may revoke this directive at any time while I have capacity

☐ I request that this directive remain in effect even if I attempt to revoke it during a crisis, UNLESS:
___________________________________________________________

Section C: Duration

This directive shall remain in effect:

☐ Indefinitely, until revoked in writing

☐ Until the following date: ___________________________________

☐ Until the following event: __________________________________

PART IX: STATE-SPECIFIC REQUIREMENTS

California

PADs are recognized under general advance directive law
Must be signed by declarant
Requires either: two adult witnesses OR notarization
Witnesses cannot be: treating provider, facility operator, or heir
File with: treating providers, hospital, agent

Texas

Governed by Health & Safety Code Chapter 137
Called "Declaration for Mental Health Treatment"
Must be signed by declarant and two witnesses
Witnesses cannot be: agent, treating provider, employee of treating provider, person related to declarant, person entitled to inherit
Valid for 3 years unless earlier revocation
Must be notarized

Florida

Recognized under general healthcare surrogate laws
Must be signed by declarant and two witnesses
One witness cannot be spouse or blood relative
Notarization recommended but not required

New York

Health Care Proxy law applies (Public Health Law Article 29-C)
Psychiatric advance directive provisions in Mental Hygiene Law
Must be signed by declarant and two adult witnesses
Agent cannot be witness
No notarization required but recommended

PART X: SIGNATURES

Declarant's Signature

I, _________________________________, being of sound mind, willfully and voluntarily make this Mental Health Advance Directive. I understand the nature and consequences of this document. I have read (or had read to me) this entire document and understand its contents.

Signature: ________________________________________________

Date: _____________________________________________________

City/State: _______________________________________________

Agent's Acceptance (if applicable)

I, _________________________________, accept the appointment as mental health care agent for the above-named declarant. I understand my duties and agree to act in accordance with the declarant's wishes as expressed in this document and to act in the declarant's best interests when wishes are not specified.

Agent Signature: __________________________________________

Date: _____________________________________________________

Alternate Agent Signature: ________________________________

Date: _____________________________________________________

Witness Signatures

WITNESS 1:

I declare that the person who signed this document, or asked another to sign for them, did so in my presence, that they appear to be of sound mind and under no duress, fraud, or undue influence.

Name: _________________________________________________________

Address: ______________________________________________________

Signature: ____________________________________________________

Date: _________________________________________________________

Relationship to Declarant: ____________________________________

☐ I am not: the declarant's healthcare provider, an employee of the declarant's healthcare provider, an operator of a healthcare facility treating the declarant, or an employee of such facility.

☐ I am not entitled to any portion of the declarant's estate.

WITNESS 2: