DECLARATION FOR MENTAL HEALTH TREATMENT
NOTICE TO PERSON MAKING A DECLARATION FOR MENTAL HEALTH TREATMENT:
This is an important legal document. It creates a declaration for mental health treatment. Before signing this document, you should know these important facts:
(1) This document allows you to make decisions in advance about three (3) types of mental health treatment: psychotropic medication, electroconvulsive therapy, and short-term (up to seventeen (17) days) admission to a treatment facility. The instructions that you include in this declaration will be followed only if a court, two (2) physicians that include a psychiatrist, OR a physician and a professional mental health clinician believe that you are incapable of making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments.
(2) You may also appoint a person as your agent to make these treatment decisions for you if you become incapable. The person you appoint has a duty to act consistent with your desires as stated in this document or, if your desires are not stated or otherwise made known to the agent, to act in a manner consistent with what the person in good faith believes to be in your best interest. For the appointment to be effective, the person you appoint must accept the appointment in writing. The person also has the right to withdraw from acting as your agent at any time.
(3) This document will continue in effect until revoked. You have the right to revoke this document in whole or in part at any time you have not been determined to be incapable. YOU MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED INCAPABLE BY A COURT, TWO (2) PHYSICIANS THAT INCLUDE A PSYCHIATRIST, OR A PHYSICIAN AND A PROFESSIONAL MENTAL HEALTH CLINICIAN. A revocation is effective when it is communicated to your attending physician or other provider.
(4) If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. This declaration will not be valid unless it is signed by two (2) qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature.
1. Declaration of Preference or Instructions: I, (Principal) , a competent adult, do hereby declare that, in the event I become incapable as defined by I.C. §66-601(4), it is my express desire that the preferences and/or instructions stated below be followed with respect to my mental health treatment:
A. Regarding electroconvulsive treatment: (Under no circumstances should I be subjected to this mode of treatment/ I should be subjected to this mode of treatment only if it my agent in good faith believes such treatment is in my best interest/ I have no preference or instructions with regard to this mode of treatment/ etc.)
B. Regarding psychotropic medication: (Under no circumstances should I be subjected to any psychotropic medication/ I should be subjected to psychotropic medication only if it my agent in good faith believes such treatment is in my best interest/ I have no preference or instructions with regard to the administration of psychotropic medication/ etc.)
C. Regarding short-term admission to a treatment facility for a period not to exceed seventeen (17) days: (Under no circumstances should I be placed in a treatment facility/ I should be placed in a treatment facility only if it my agent in good faith believes such placement is in my best interest/ I have no preference or instructions with regard to being placed in a treatment facility for short-term admission/ etc.)
2. Designation of Agent(s): I do not wish to designate a person to act as my attorney-in-fact (agent) to make decisions about my mental health treatment in the event I become incapable as defined by I.C. §66-601(4).
Or
I, do hereby designate the following person, a competent adult, to act as my attorney-in-fact (agent) to make decisions about my mental health treatment in the event I become incapable as defined by I.C. §66-601(4).
Name:
Residence:
I also designate the following person, a competent adult, as my alternative attorney-in-fact (agent) to make decisions about my mental health treatment in the event I become incapable, if the original designee is unable or unwilling to act at any time.
Name:
Residence:
[The appointment of an alternative agent is optional]
3. Powers of Agent:
A. An agent who has accepted the appointment in writing may make decisions on my behalf only when I am incapable as defined by I.C. §66-601(4).
B. In exercising the authority granted herein, the agent shall act consistently with my expressed preferences and/or instructions as stated in this document or, if my preferences and/or instructions are not stated or otherwise made known to the agent, the agent shall act in a manner consistent with what he or she in good faith believes to be in my best interest.
C. Except to the extent limited by this declaration or any federal law, the agent has the same right as I would, if I were not incapable, to receive information regarding the proposed mental health treatment and to receive, review and consent to the disclosure of medical records relating to that treatment.
D. The authority of the agent continues in effect as long as this declaration appointing the agent is in effect or until the agent has withdrawn.
4. Prior Designations Revoked: I revoke any prior Declarations for Mental Health Treatment.
5. Signature: I sign my name to this Declaration for Mental Health Treatment on this day of , 19 , at , Idaho.
(signature of Principal)
Statement of Witnesses
I declare under penalty of perjury under the laws of Idaho that the person who signed or acknowledged this Declaration for Mental Health Treatment, the principal, is personally known to me, signed the Declaration in my presence, appeared to be of sound mind, and was not under duress, fraud or undue influence. I further declare that I am not the principal's attending physician or mental health provider or a relative of such physician or provider; an owner, operator, or relative or operator of a health care facility in which the principal is a patient or resident; or a person related to the principal by blood, marriage or adoption.
Signature:
Print name:
Date:
Residence:
Signature:
Print name:
Date:
Residence: