Mental Health Association in Pennsylvania 2008

MENTAL HEALTHADVANCE DIRECTIVESFOR PENNSYLVANIANS

MENTAL HEALTH ADVANCE DIRECTIVE

Instructions and Forms

I, _________________________________,have executed an advance directive specifying my decisions about my mental health care. My Mental

Health Care Agent is ______________________.If I am hospitalized, my Agent should be immediately

contacted at _______ - ________- ___________.

MENTAL HEALTH ADVANCE DIRETIVES MENTAL HEALTH ADVANCDIRECTIVES MENTAL HEALTHADVANCE DIRECTIVES MENTALHEALTH ADVANCE DIRECTIVES TAL HEALTH ADVANCE DIRECTIVMENTAL HEALTH ADVANCE DIRETIVES MENTAL HEALTH ADVANCDIRECTIVES MENTAL HEALTHADVANCE DIRECTIVES MENTALHEALTH ADVANCE DIRECTIVES TAL HEALTH ADVANCE DIRECTIVMENTAL HEALTH ADVANCE DIRETIVES MENTAL HEALTH ADVANCDIRECTIVES MENTAL HEALTHADVANCE DIRECTIVES MENTALHEALTH ADVANCE DIRECTIVES TAL HEALTH ADVANCE DIRECTIVMENTAL HEALTH ADVANCE DIRETIVES MENTAL HEALTH ADVANCDIRECTIVES MENTAL HEALTHADVANCE DIRECTIVES MENTAL

If the hospital has questions about its legal

responsibilities to honor my decisions,

it should contact

Disability Rights Network of Pennsylvania at:

1-800-692-7443.

I. INTRODUCTION ...................................................p. 3

II. FREQUENTLY ASKED QUESTIONS........................p. 4

III. COMBINED MENTAL HEALTH .............................p. 7DECLARATION / POWER OF ATTORNEY

● Instructions

IV. MENTAL HEALTH DECLARATION........................p. 13● Instructions

V. MENTAL HEALTH POWER OF ATTORNEY ......... p. 19● Instructions

VI. GLOSSARY OF TERMS.......................................p. 24

VII. FORMS...............................................................p. 25● Combined (p. 27)● Declaration (p. 35)● Power of Attorney (p. 41)

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Table ofContents

On November 30, 2004, Governor Rendell signed House Bill 2036 into law making it Act 194 of 2004.

By allowing you to create a Mental Health Advance Directive – which can include a Declaration and/or a

Mental Health Power of Attorney – this new law promotes planning ahead for the mental health services

and supports that you might want to receive during a crisis if you are unable to make decisions.

Act 194 became effective on January 29, 2005. The passage of this legislation is largely the

result of collaboration between advocacy organizations, county governments, professional

associations and the state government. A Mental Health Care Advance Directive is a tool that focuses

on wellness and recovery planning. Pennsylvania is pleased to join the national trend

of promoting the use of this tool as a mental health policy.

It is important to understand how to make this new law work for you – including how to create

an Advance Directive and/or appoint an agent for your mental health Power of Attorney.

This booklet has been developed to assist you. It includes forms and instructions that you

can use to create your advance directive and answers to frequently asked questions. If you have

additional questions or need assistance with completing a form, contact any one of the following

organizations:

● Pennsylvania Mental Health Consumers’ Association1-800-88PMHCApmhca@pmhca.org

● Disability Rights Network of Pennsylvania1-800-692-7443717-236-81101-877-375-7139 (TDD/TTY)

● Mental Health Association in Pennsylvania1-866-578-3659717-346-0549info@mhapa.org

I. INTRODUCTION

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What is a Mental Health Advance Directive?A Mental Health Advance Directive is a documentthat allows you to make your choices knownregarding mental health treatment in the event thatyour mental illness makes you unable to makedecisions. In effect, you are making decisions abouttreatment before the time that you will need it. Thisallows you to make more informed decisions and tomake your wishes clearly known. A new law waspassed in Pennsylvania, effective January 29, 2005,that makes it possible for you to use a MentalHealth Advance Directive.

Many decisions may need to be made for you ifyou have a mental health crisis or are involuntarilycommitted and become unable to make treatmentdecisions. For example, the choice of hospital,types of treatment, and who should be notified aredecisions that may be made for you.

Unfortunately, at the time of crisis, you may not beable to make your wishes known, and therefore youmay end up with others making decisions that youwould not make. One way to be sure that your doc-tor, relatives, and friends understand your feelingsis to prepare a Mental Health Advance Directivebefore you become unable to make decisions.Pennsylvania law allows you to make a MentalHealth Advance Directive that is a Declaration, aPower of Attorney, or a combination of both.

What is a Declaration?A Declaration contains instructions to doctors, hos-pitals, and other mental health care providers aboutyour treatment in the event that you become unableto make decisions or unable to communicate yourwishes. A Declaration usually deals with specificsituations and does not allow much flexibility forchanges that come up after the document is written,such as a new type of medical crisis, new kinds ofmedication, or different treatment choices.

What is a Mental Health Power of Attorney?A Mental Health Power of Attorney allows you todesignate someone else, called an agent, to maketreatment decisions for you in the event of a mentalhealth crisis. A Mental Health Power of Attorneyprovides flexibility to deal with a situation as itoccurs rather than attempting to anticipate every

possible situation in advance. When using a Mental Health Power of Attorney it is very important to choose someone you trust as youragent and to spend time with that person explainingyour feelings about treatment choices. Your doctoror his/her employee, or an owner, operator, oremployee of a residential facility where you are staying cannot serve as an agent.

What is a Combined Mental Health Declaration andPower of Attorney?Pennsylvania’s law also allows you to make a combined Mental Health Declaration and Power ofAttorney. This lets you make decisions about somethings, but also lets you give an agent power tomake other decisions for you. You choose the deci-sions that you want your agent to make for you, asmany or as few as you like. This makes yourMental Health Advance Directive more flexible indealing with future situations, such as new treat-ment options, that you would have no way ofknowing about now.

Your agent should be someone you trust, and youshould be sure to discuss with your agent your feel-ings about different treatment choices so that youragent can make decisions that will be most like theones you would have made for yourself.

What makes a Mental Health Care Advance Directivevalid?There is no specific form that must be used, but your Mental Health Advance Directive must meetthe following requirements:

1. You must be at least 18 years of age.2. You must not have been declared incapacitat-

ed by a court and had a guardian appointed orcurrently be under an involuntary commitment.

3. The Mental Health Advance Directive mustbe signed, witnessed and dated. Witnessesmust be at least 18 years old. If you cannotphysically sign the document, another personmay sign for you, but the person signing maynot also be a witness.

4. The Mental Health Advance Directive mustcontain your choices about beginning, contin-uing, or refusing mental health treatment.The Mental Health Advance Directive also

II. FREQUENTLY ASKED QUESTIONS

4

can include choices about other things, suchas who you want to be your agent orguardian, who you want to care for yourchildren or pets, who you want notifiedabout your condition, and/or your dietary orreligious choices.

5. If your Mental Health Advance Directive is aPower of Attorney, then you must name theperson you want to be your agent and saythat you are authorizing them to makewhatever decisions you want them to make.Your doctor or his/her employee, or anowner, operator, or employee of a residentialfacility where you are staying cannot serveas an agent.

The Mental Health Advance Directive is valid fortwo years from the date you sign it unless one ofthe following happens first:

a. You revoke the entire Mental HealthAdvance Directive, or

b. You make a new Mental Health AdvanceDirective.

If you do not have capacity to make treatment decisions at the time the Mental Health AdvanceDirective ends, the Advance Directive will stay inplace until you are able to make treatment decisions.

What is Capacity? Capacity is the basic ability to understand yourdiagnosis and to understand the risks, benefits, andalternative treatments of your mental health care.It also includes the ability to understand what mayhappen if you do not receive treatment.

Do I need to include proof of my capacity with the document?No, unless you have a guardian or are currentlyunder an involuntary commitment, you are pre-sumed to have capacity when you make a MentalHealth Advance Directive. However, at a later timeit is possible for someone to challenge whetheryou had capacity. If you want to be very sure thatno one can challenge your Mental Health AdvanceDirective later, you can include a letter from yourtreating doctor from the same time period that youmade your directive stating that you had capacityat that time.

When would my Mental Health Advance Directive take effect?You can write in your Mental Health Advance

Directive when you want the directive to takeeffect, for example, when involuntary commitmentoccurs, or when a psychiatrist and another mentalhealth treatment professional state that you nolonger have capacity to make mental health treatmentdecisions.

Who will determine that I don’t have capacity to makemental health decisions?For the purpose of your Mental Health AdvanceDirective, incapacity will be determined after youare examined by a psychiatrist and one of the fol-lowing: another psychiatrist, psychologist, familyphysician, attending physician, or mental healthtreatment professional. Whenever possible, one ofthe decision makers will be one of your currenttreating professionals.

What if a court appoints a guardian after I haveappointed an agent to make my mental health caredecisions?In your Advance Directive you can name someoneyou want the court to choose as your guardian.The court will appoint the person you choose,unless there is a good reason not to. In many casesyour agent and the person you would want to beyour guardian would be the same person.

However, you may want one person to make yourmental health care decisions, and someone else tomake other decisions for you. If the court-appointedguardian and your agent are different people, thecourt will allow your agent to make mental healthcare decisions, unless you say otherwise in yourMental Health Advance Directive. If the courtdecides to grant the powers that you gave to anagent to the guardian, the guardian would still haveto make decisions as written in your AdvanceDirective.

May I make changes to my Mental Health AdvanceDirective?You may change your Mental Health AdvanceDirective in writing at any time, as long as youhave capacity. If you make significant changes,you should make a new document so that there areno conflicts or misunderstandings. Remember thatyour changes or a new directive must be witnessedby two individuals, at least 18 years of age, andyou should give new copies to your provider,agent, and other support people.

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May I revoke my Mental Health Advance Directive?You may revoke, or in other words, cancel, a partor the whole Mental Health Advance Directive atany time, as long as you have capacity. This maybe done either orally or in writing. It is effective assoon as you tell your provider. Your AdvanceDirective will automatically end after two yearsfrom the date you signed it unless you do not havecapacity to make mental health care decisions atthat time. If you do not have capacity at the time itwould end, the Mental Health Advance Directivewill stay in force until you regain capacity.

What types of instructions should I include?A Mental Health Advance Directive is a way tocommunicate lots of information to your provider.You may wish to include your choices about different treatment options, such as medications,electro-shock therapy, and crisis management. In addition, you may say who you want to be toldin the event of a crisis, or write down your dietarychoices, past treatment history, who you want totake care of your children or pets, and other information that you want to be taken care of while you seek treatment.

Who should I give my Mental Health Advance Directive to?The only way that your providers will know whatyour choices are is if you give them your MentalHealth Advance Directive. You should also givecopies to your treating physician, agent, and familymembers or other people that would be notified inthe event of a crisis. Keep the original in a safeplace, and be sure that someone who would be toldof any crisis can get the original so it can be givento the attending physician. You may wish to carry acard in your wallet stating that you have a MentalHealth Advance Directive, and who should becalled in the event that you lack capacity to makemental health care decisions. Include that person’sphone numbers, and also name another person incase the first person is not available. Rememberthat if you make changes or create a new MentalHealth Advance Directive you must be sure thateveryone has copies of the most recent version.

Do health care providers have to follow my instructions?Yes, unless a provider cannot in good conscience comply with your instructions because they areagainst accepted clinical or medical practice, orbecause the policies of the provider, such as what iscovered by insurance, do not allow compliance, orbecause the treatment is physically unavailable. Ifthe provider cannot comply for any of these reasons,the provider must tell you or your agent as soon aspossible. It is very helpful to discuss your decisionswith your provider when you make your MentalHealth Advance Directive, so that you know whetherthey will be able to follow your instructions.

Remember that even if you consent in advance to aparticular medication or treatment, your doctor willnot prescribe that treatment or drug unless it isappropriate at the time you are ill. Your consent isonly good if your choices are okay at that time,within the standards of medical care. Your doctorwill also have to consider if a particular treatmentoption is covered by your insurance. If, for exam-ple, the HMO that you have does not cover a cer-tain drug on its formulary, your doctor may pre-scribe a drug that is similar, but is on the HMO for-mulary, as long as you have not withheld consent tothat particular drug.

How does a Mental Health Advance Directive affectinvoluntary commitment?The voluntary and involuntary commitment provi-sions of the Mental Health Procedures Act are notaffected by having a Mental Health Care AdvanceDirective. What may be affected is how you canbe treated after you are committed.

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COMBINED Mental Health Declarationand Power of Attorney

Pennsylvania’s law allows you to make a combinedMental Health Declaration and Power of Attorney.This lets you make decisions about some things,but also lets you give an agent power to make otherdecisions for you. You choose the decisions thatyou want your agent to make for you, as many oras few as you like. This makes your Mental HealthAdvance Directive more flexible in dealing withfuture situations, such as new treatment options,that you would have no way of knowing aboutnow.

You are presumed to be capable of making anAdvance Directive unless you have been adjudicat-ed, incapacitated, involuntarily committed, orfound to be incapable of making mental healthdecisions after examination by both a psychiatristand another doctor or mental health professional.

Basic InstructionsThe following corresponds to the form on page 27.

Read each section very carefully. Begin by print-ing your name in the blank in the introductoryparagraph at the top of the page.

Part I: Introduction

A. When this Declaration becomes effectiveDecide when you want the Declaration to becomeeffective. You can specify a condition, such as ifyou are involuntarily committed for either outpa-tient or inpatient care, or some other behavior orevent that you know happens when you no longerhave capacity to make mental health decisions, oryou can specify that you want an evaluation forincapacity.

If you do not choose a condition, your incapacitywill be determined after examination by a psychia-trist and one of the following: another psychiatrist,psychologist, family physician, attending physician,or other mental health treatment professional. If youhave doctors that you would prefer to make theevaluation, you should specify them in yourDeclaration. Although that doctor may not be avail-able, an effort will at least be made to contact them.

Until your condition is met, or you are found to beunable to make mental health decisions, you willmake decisions for yourself.

B. Revocations and AmendmentsRevocation means that you are canceling yourDirective. If you revoke your Directive, your doc-tor will no longer have to follow the instructionsthat you gave in the document. You may change orrevoke your Directive at any time, as long as youhave capacity to make mental health decisionswhen you make the change or revocation. Youmay revoke a specific instruction without revokingthe entire document.

If you are currently under an involuntary commit-ment and you want to change or revoke your Declaration, you will need to request an evaluationto determine if you are capable of making mentalhealth decisions. The evaluation will be done by apsychiatrist and another psychiatrist, psychologist,family physician, attending physician or other men-tal health professional. If you are found to havethe capacity to make mental health decisions, youwill be able to revoke or change your Declaration,even though you are in the hospital.

You may revoke your Mental Health AdvanceDirective orally or in writing. Your AdvanceDirective will terminate as soon as you communi-cate your revocation to your treating doctor. It isbest to make any changes or revocation in writing,because then there is a clear record of your wishes.

If you make a new Mental Health Advance Directive,you should be sure to notify your doctor and sup-port people that you have revoked the old one.Your Directive will automatically expire two yearsfrom the date you made it, unless you are unable tomake mental health decisions for yourself at thetime it would expire. In that case, it will remain inforce until you are able to make decisions for yourself.

To amend your Directive means that you makechanges to it. You may make changes at any time,as long as you have capacity to make mental healthcare decisions. Any changes must be made in writ-

III. COMBINED

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ing and be signed and witnessed by two individu-als in the same way as the original document. Anychanges will be effective as soon as the changesare communicated to your attending physician orother mental health care provider, either by you, ora witness to your amendments.

C. TerminationYour Advance Directive will automatically expiretwo years from the date of execution, unless youhave been found incapable of making mentalhealth care decisions at the time the directivewould expire. In that case, the Declaration willcontinue to be in force until you regain capacity.

Part II: Mental Health Declaration

A. Treatment preferencesYour Advance Directive will be less likely to bechallenged if you include information about whatyou do want, as well as what you don’t want.

Remember that consenting in advance to a particu-lar medication or treatment does not mean yourdoctor will prescribe that treatment or drug unless itis appropriate treatment at the time you are ill.Consent only means that you consent if it is a suit-able choice at that time within the standards ofmedical care. Your doctor will also have to consid-er if a particular treatment option is covered byyour insurance. If, for example, the HMO that youhave does not cover a certain drug on its formulary,your doctor may prescribe a drug that is similar, butis on the HMO formulary as long as you have notwithheld consent to that particular drug.

Make sure to mark your preference in each sectionwith your initials. Although you do not have toexplain your choices, it is helpful if you includestatements explaining why you want or don’t wantany specific treatments. If any of your choices arechallenged, you will have a better chance of hav-ing your choice honored if a court understandswhat your reasons are for making your choice. Ifyou do not have a preference in a given section,you may leave it blank.

1. Choice of Treatment FacilityIf you have a preference for, or bad feelingstoward, any particular hospital, list them here.Unfortunately, there are times when a particu-

lar place is already full and would be unable toaccommodate you, or the treating doctor doesnot have privileges at the hospital you wouldprefer. Therefore, although your doctor willtry to respect your choice, it may not alwaysbe possible.

2. MedicationsIf you give instructions about medications, be

sure to give reasons for your decisions. If, forinstance, you experienced unacceptable sideeffects from a particular generic or dose, youwould want to be specific so that your treatingdoctor understands your concern. That wayyour doctor will be less likely to prescribesomething else that is likely to cause similarproblems. Likewise, if you know that a specif-ic medication has worked for you in the past,you should be sure to include that information.If a time-released version works, but the regu-lar brand does not, you should be sure youinclude that information. The more your doc-tor knows about you, the more likely you areto get the right treatment, faster.

Be careful what you specify. Medicationscome in brand and generic names, and alsobelong to broader classes of drugs, such as“atypical antipsychotics” or “SSRIs.” If yourule out an entire class of drugs, you should beaware that a new, helpful drug may come onthe market that could be ruled out, even thoughyou don’t actually know anything about it.

You may choose to let your agent make deci-sions related to the use of medications. If youchoose this option, be sure to discuss yourfeelings and prior experiences with your agent.

You may choose not to consent to the use ofany medications. Just be aware that you willalso be ruling out new medications that couldbe helpful in your treatment. Your AdvanceDirective may also be challenged if your doc-tor believes that you will be irreparablyharmed by this choice.

3. Preferences related to electroconvulsivetherapy (ECT)In some cases, a doctor may find that ECTwould be an effective form of treatment. If

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you have found ECT helpful in the past, or youtrust your doctor to make that decision on yourbehalf, you may decide to consent to this treat-ment in advance.

You may choose to let your agent make deci-sions related to ECT. If you choose thisoption, be sure to discuss your feelings andprior experiences with ECT with your agent.

If you do not wish to undergo ECT under anycircumstances, you should initial the line nextto “I do not consent to the administration ofelectroconvulsive therapy.” NOTE: Youragent is NOT allowed to consent to ECTunless you initial this authorization.

4. Preferences for experimental studiesOpportunities may exist for you to participatein experimental studies related to treatment ofyour illness. Sometimes these studies providemore data that helps doctors determine thecause or best practice for treating an illness.Sometimes the studies are based on the ideathat a certain new treatment might help. If youparticipate in a study, you may have access to anew treatment sooner than you would other-wise. However, there may be some level ofrisk involved. If you want to participate in astudy because your doctor believes that thepotential benefits to you outweigh the potentialrisks, you should initial the first choice.

You may choose to let your agent make deci-sions related to your participation for experi-mental studies. It is important that your agentunderstand the kind of studies that you wouldobject to. For example, you may wish to partic-ipate only if the study does not include medica-tion or any invasive procedures.

If you do not want to participate in experimen-tal studies of any kind, under any circum-stances, you should initial the choice that statesthat you do not consent. NOTE: Your agent isNOT allowed to consent to experimentalstudies unless you initial this authorization.

5. Preferences regarding drug trialsSimilarly, you may have the opportunity to par-ticipate in a trial related to new medications. If

you participate, you may have access to a newdrug sooner than you would otherwise.However, there may be risks or side effects. Ifyou want to participate in a drug trial if yourdoctor believes that the potential benefits toyou outweigh the potential risks, you shouldinitial the first choice.

You may choose to let your agent make deci-sions related to your participation in drug trials.It is important that your agent understand anyparticular risks that you would not be willing totake so that he/she can make the decision youwould make given the same information.

If you do not want to participate in a drug trialof any kind, under any circumstances, youshould initial the choice that states that you donot consent. NOTE: Your agent is NOTallowed to consent to research includingdrug trials unless you initial this authoriza-tion.

6. Additional instructions or informationOne of the significant benefits of filling out anAdvance Directive is that you are communicat-ing important information to your mentalhealth care provider, agent, and others whosupport you. This part of your form allows youto provide information that may or may not bedirectly related to your mental health treatment.If there is other information that you wouldlike your mental health care provider and agentto know you should include it here. You canattach an additional page to the form if there isnot enough room to write everything you needto. Just be sure that you print or type yourstatements, and try to make them as clear aspossible, to minimize confusion about whatyou want to happen. Again, if you do not havea preference about something listed or you arecomfortable letting your agent make that par-ticular decision, just leave that particular sec-tion blank.

Part III: Mental Health Power of Attorney

Begin by printing your name in the blank in thefirst paragraph stating that you are authorizing adesignated health care agent to make certain deci-sions on your behalf.

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A. Designation of AgentYou may name any adult who has capacity as your agent, with the following exceptions: yourmental health care provider or an employee of your mental health care provider or an agent, operator, or employee of a residential facility inwhich you are receiving care may not serve as your agent unless they are related to you by mar-riage, blood or adoption.

Write in the name of the person you choose, andfill in their address and phone number. You wantthe person to be contacted anytime, so add asmuch information as possible, including work andhome phone numbers. The person that you chooseas your agent should also sign the document toindicate that he/she accepts serving as your agent.

Since your agent will be making decisions on yourbehalf, it is very important to choose someone youtrust and to discuss your ideas and feelings indetail so that the person really understands whatmental health decisions you would have made foryourself.

B. Designation of an Alternative AgentYou may wish to designate an alternative person incase the first person you chose is unavailable. Thisis a good idea if you have another person that youtrust, since people may be unavailable for a varietyof reasons such as illness or travel. If you do nothave any one that you wish to name as an alterna-tive, leave this section blank.

The person that you choose as your alternativeagent should also sign the document to indicatethat he/she accepts serving as your agent. Youralternative agent must fill in his/her address andphone number so that they can be reached by yourprovider.

C. Authority Granted to AgentYou may grant full power and authority to youragent to make all of your mental health care deci-sions, or you can set limits on the kinds of deci-sions your agent may make on your behalf. If youwish to limit the decisions your agent can makeyou should read each subsection carefully and ini-tial your choice. Your agent cannot consent toelectroconvulsive therapy, experimental proceduresor research unless you expressly grant those pow-

ers by initialing consent in those sections. If thereis some other mental health care decision that youdo not want your agent to be able to make, youmay write it in. Be sure to write clearly, so there isno room for confusion.

The Pennsylvania law does not allow your agent toconsent to psychosurgery or the termination ofparental rights on your behalf, even if you are will-ing for your agent to have that power.

Part IV: Nominating a Guardian

A. Preference as to a court-appointed guardianIf you become incapacitated, it is possible that acourt may appoint a guardian to act on your behalf.Under the guardianship laws, you may nominate aguardian of your person for consideration by thecourt. The court will appoint your guardian inaccordance with your most recent nominationexcept for good cause or disqualification. If youwish to name someone in your Declaration, it isimportant that you talk to that person aboutwhether they feel they can serve as your guardian,because a court will not force them to serve. It isalso important that you give that person a copy ofyour Power of Attorney and explain your wishesregarding mental health treatment.

If the court appoints a guardian, that person willnot be able to terminate, revoke or suspend yourDeclaration unless you want them to be able to. Inthis section, you should decide whether you want acourt appointed guardian to have that power. Evenif you do not specify a person that you would wantas a guardian, you can still specify whether a per-son that is appointed by the court is allowed to ter-minate, revoke or suspend your Declaration.

If the court-appointed guardian and your agent turnout to be different people, the court will give pref-erence to allowing your mental health care agent tocontinue making mental health care decisions asprovided in your Directive, unless you specify oth-erwise in your Directive. If, after thorough exami-nation, the court decides to grant the powers thatyou gave to an agent to the guardian, the guardianwould still be bound by the same obligations thatyour agent would have been.

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Part V. Execution

You must sign and date your Combined MentalHealth Care Declaration and Power of Attorneyin this section. If you are unable to sign for your-self, someone else may sign on your behalf.Your document must be signed and dated by youin the presence of two witnesses. Each witnessmust be at least 18 years old. The witnesses maynot be your agent or a person signing on yourbehalf.

In order for your Declaration to be effective, youmust be sure that the right people have access to it.Be sure to give copies of this Advance Directive toyour agent, mental health care provider, and anyoneelse that may be notified in the event that you arefound not to have capacity to make mental healthcare decisions. Remember that if you cancel orchange your document you must let everyone know.It is a good idea to carry a card in your wallet to letpeople know that you have an Advance Directive.

Please Note: The information in this document isnot intended to constitute legal advice applicable tospecific factual situations. For specific advice con-tact the Disability Rights Network of Pennsylvania(DRN) intake line at 1-800-692-7443 (voice) or 1-877-375-7139 (TDD).

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MENTAL HEALTH Declaration

A Declaration contains instructions to doctors, hos-pitals, and other mental health care providers aboutyour treatment in the event that you become unableto make decisions or unable to communicate yourwishes. A Declaration usually deals with specificsituations and does not allow much flexibility forchanges that come up after the document is written,such as a new type of medical crisis, new kinds ofmedication, or different treatment choices.

You are presumed to be capable of making anAdvance Directive unless you have been adjudicat-ed, incapacitated, involuntarily committed, or foundto be incapable of making mental health decisionsafter examination by both a psychiatrist and anotherdoctor or mental health professional.

Basic InstructionsThe following corresponds to the form on page 35.

Read each section very carefully. Begin by print-ing your name in the blank in the introductory para-graph at the top of the page.

A. When this Declaration becomes effectiveDecide when you want the Declaration to becomeeffective. You can specify a condition, such as ifyou are involuntarily committed for either outpa-tient or inpatient care, or some other behavior orevent that you know happens when you no longerhave capacity to make mental health decisions, oryou can specify that you want an evaluation forincapacity.

If you do not choose a condition, your incapacitywill be determined after examination by a psychia-trist and one of the following: another psychiatrist,psychologist, family physician, attending physician,or other mental health treatment professional. Ifyou have doctors that you would prefer to make theevaluation, you should specify them in yourDeclaration. Although that doctor may not be avail-able, an effort will at least be made to contact them.

Until your condition is met, or you are found to beunable to make mental health decisions, you willmake decisions for yourself.

B. Treatment preferencesYour Advance Directive will be less likely to bechallenged if you include information about whatyou do want, as well as what you don’t want.

Remember that consenting in advance to a particu-lar medication or treatment does not mean yourdoctor will prescribe that treatment or drug unless itis appropriate treatment at the time you are ill.Consent only means that you consent if it is a suit-able choice at that time within the standards ofmedical care. Your doctor will also have to consid-er if a particular treatment option is covered byyour insurance. If, for example, the HMO that youhave does not cover a certain drug on its formulary,your doctor may prescribe a drug that is similar, butis on the HMO formulary as long as you have notwithheld consent to that particular drug.

Make sure to mark your preference in each sectionwith your initials. Although you do not have toexplain your choices, it is helpful if you includestatements explaining why you want or don’t wantany specific treatments. If any of your choices arechallenged, you will have a better chance of havingyour choice honored if a court understands whatyour reasons are for making your choice. If you donot have a preference in a given section, you mayleave it blank.

1. Choice of Treatment FacilityIf you have a preference for, or bad feelingstoward, any particular hospital, list them here.Unfortunately, there are times when a particularplace is already full and would be unable toaccommodate you, or the treating doctor doesnot have privileges at the hospital you wouldprefer. Therefore, although your doctor will tryto respect your choice, it may not always bepossible.

2. MedicationsIf you give instructions about medications, besure to give reasons for your decisions. If, forinstance, you experienced unacceptable sideeffects from a particular generic or dose, youwould want to be specific so that your treating

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IV. DECLARATION

doctor understands your concern. That wayyour doctor will be less likely to prescribesomething else that is likely to cause similarproblems. Likewise, if you know that a spe-cific medication has worked for you in thepast, you should be sure to include that infor-mation. If a time-released version works, butthe regular brand does not, you should be sureyou include that information. The more yourdoctor knows about you, the more likely youare to get the right treatment, faster.

Be careful what you specify. Medicationscome in brand and generic names, and alsobelong to broader classes of drugs, such as“atypical antipsychotics” or “SSRIs.” If yourule out an entire class of drugs, you shouldbe aware that a new, helpful drug may comeon the market that could be ruled out, eventhough you don’t actually know anythingabout it.

You may choose not to consent to the use ofany medications. Just be aware that you willalso be ruling out new medications that couldbe helpful in your treatment. Your AdvanceDirective may also be challenged if your doc-tor believes that you will be irreparablyharmed by this choice.

3. Preferences related to electroconvulsivetherapy (ECT)In some cases, a doctor may find that ECTwould be an effective form of treatment. Ifyou have found ECT helpful in the past, oryou trust your doctor to make that decision onyour behalf, you may decide to consent to thistreatment in advance.

If you do not wish to undergo ECT under anycircumstances, you should initial the line nextto “I do not consent to the administration ofelectroconvulsive therapy.”

4. Preferences for experimental studiesOpportunities may exist for you to participatein experimental studies related to treatment ofyour illness. Sometimes these studies providemore data that help doctors determine thecause or best practice for treating an illness.

Sometimes the studies are based on the ideathat a certain new treatment might help. If youparticipate in a study, you may have access toa new treatment sooner than you would other-wise. However, there may be some level ofrisk involved. If you want to participate in astudy because your doctor believes that thepotential benefits to you outweigh the poten-tial risks, you should initial the first choice.

If you do not want to participate in experi-mental studies of any kind, under any circum-stances, you should initial the choice thatstates that you do not consent.

5. Preferences regarding drug trialsSimilarly, you may have the opportunity toparticipate in a trial related to new medica-tions. If you participate, you may have accessto a new drug sooner than you would other-wise. However, there may be risks or sideeffects. If you want to participate in a drugtrial because your doctor believes that thepotential benefits to you outweigh the poten-tial risks, you should initial the first choice.

If you do not want to participate in a drug trialof any kind, under any circumstances, youshould initial the choice that states that you donot consent.

6. Additional instructions or informationOne of the significant benefits of filling out anAdvance Directive is that you are communi-cating important information to your doctorand people who support you. This part ofyour form allows you to provide informationthat may or may not be directly related toyour mental health treatment. If there is otherinformation that you would like your doctor toknow, you should include it here. You canattach an additional page to the form if thereis not enough room to write everything youneed to. Just be sure that you print or typeyour statements, and try to make them as clearas possible, to minimize confusion about whatyou want to happen. Again, if you do nothave a preference about something listed, justleave that particular section blank.

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C. Revocations and AmendmentsRevocation means that you are canceling yourDeclaration. If you revoke your Declaration, yourdoctor will no longer have to follow the instruc-tions that you gave in the document. You maychange or revoke your Declaration at any time, aslong as you have capacity to make mental healthdecisions when you make the change or revocation.You may revoke a specific instruction withoutrevoking the entire document.

If you are currently under an involuntary commit-ment, and you want to change or revoke yourDeclaration, you will need to request an evaluationto determine if you are capable of making mentalhealth decisions. The evaluation will be done byboth a psychiatrist and another psychiatrist, psy-chologist, family physician, attending physician orother mental health professional. If you are foundto have the capacity to make mental health deci-sions, you will be able to revoke or change yourDeclaration, even though you are in the hospital.

You may revoke your Declaration orally or in writ-ing. It becomes effective as soon as you communi-cate your revocation to your treating doctor. It isbest to make any changes or revocation in writing,because then there is a clear record of your wishes.

If you make a new Declaration, you should be sureto notify your doctor and support people that youhave revoked the old one. Your Declaration willautomatically expire two years from the date youmade it, unless you are unable to make mentalhealth decisions for yourself at the time it wouldexpire. In that case, it will remain in force untilyou are able to make decisions for yourself.

To amend your Declaration means that you makechanges to it. You may make changes at any time,as long as you have capacity to make mental healthcare decisions. Any changes must be made in writ-ing and be signed and witnessed by two individualsin the same way as the original document. Anychanges will be effective as soon as the changes arecommunicated to your attending physician or othermental health care provider, either by you, or a wit-ness to your amendments.

D. TerminationYour Declaration will automatically expire twoyears from the date of execution, unless you havebeen found incapable of making mental health caredecisions at the time the directive would expire. Inthat case, the Declaration will continue to be inforce until you regain capacity.

E. Preference as to a court-appointed guardianIf you become incapacitated, it is possible that acourt may appoint a guardian to act on your behalf.Under the guardianship laws, you may nominate aguardian of your person for consideration by thecourt. The court will appoint your guardian inaccordance with your most recent nominationexcept for good cause or disqualification. If youwish to name someone in your Declaration, it isimportant that you talk to that person about whetherthey feel they can serve as your guardian, because acourt will not force them to serve. It is also impor-tant that you give that person a copy of yourDeclaration and explain your wishes regarding men-tal health treatment.

If the court appoints a guardian, that person will notbe able to terminate, revoke or suspend yourDeclaration unless you want them to be able to. Inthis section, you should decide whether you want acourt appointed guardian to have that power. Evenif you do not specify a person that you would wantas a guardian, you can still specify whether a per-son that is appointed by the court is allowed to ter-minate, revoke or suspend your Declaration.

F. ExecutionYou must sign and date your Declaration in thissection. If you are unable to sign for yourself, some-one else may sign on your behalf. Your documentmust be signed and dated by you in the presenceof two witnesses. Each witness must be at least 18years old. If you are unable to sign the documentyourself, you may have someone else sign on yourbehalf, but that person may not also be a witness.

In order for your Declaration to be effective, youmust be sure that the right people have access to it.Be sure to give copies of this Advance Directive toyour mental health care provider, and anyone else

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that may be notified in the event that you arefound not to have capacity to make mental healthcare decisions. Remember that if you cancel orchange your document you must let everyoneknow. It is a good idea to carry a card in yourwallet to let people know that you have anAdvance Directive.

Please Note: The information in this document isnot intended to constitute legal advice applicableto specific factual situations. For specific advicecontact the Disability Rights Network ofPennsylvania (DRN) intake line at 1-800-692-7443 (voice) or 1-877-375-7139 (TDD).

MENTAL HEALTH Power of Attorney

A Power of Attorney allows you to designate some-one else, called an agent, to make treatment deci-sions for you in the event of a mental health crisis.A Power of Attorney provides flexibility to dealwith a situation as it occurs rather than attempting toanticipate every possible situation in advance.When using a Power of Attorney it is very importantto choose someone you trust as your agent and tospend time with that person explaining your feelingsabout treatment choices. Your doctor or his/heremployee, or an owner, operator, or employee of aresidential facility where you are staying cannotserve as an agent.

You are presumed to be capable of making anAdvance Directive unless you have been adjudicat-ed, incapacitated, involuntarily committed, or foundto be incapable of making mental health decisionsafter examination by both a psychiatrist and anotherdoctor or mental health professional.

Basic InstructionsThe following corresponds to the form on page 41.

Read each section very carefully. Begin by print-ing your name in the blank in the introductory para-graph at the top of the page.

A. Designation of AgentYou may name any adult who has capacity as youragent, with the following exceptions: your mentalhealth care provider or an employee of your mentalhealth care provider or an agent, operator, or employ-ee of a residential facility in which you are receivingcare may not serve as your agent unless they arerelated to you by marriage, blood or adoption.

Write in the name of the person you choose, and fillin their address and phone number. You want theperson to be contacted anytime, so add as muchinformation as possible, including work and homephone numbers. The person that you choose as youragent should also sign the document to indicate thathe/she accepts serving as your agent.

Since your agent will be making decisions on yourbehalf, it is very important to choose someone youtrust and to discuss your ideas and feelings in detailso that the person really understands what mentalhealth decisions you would have made for yourself.

B. Designation of an Alternative AgentYou may wish to designate an alternative person incase the first person you chose is unavailable. Thisis a good idea if you have another person that youtrust, since people may be unavailable for a varietyof reasons such as illness or travel. If you do nothave any one that you wish to name as an alterna-tive, leave this section blank.

The person that you choose as your alternativeagent should also sign the document to indicate thathe/she accepts serving as your agent. Your alterna-tive agent should fill in his/her address and phonenumber so that they can be reached by yourprovider.

C. When the Power of Attorney becomes effectiveDecide when you want the Power of Attorney tobecome effective. You can specify a condition,such as if you are involuntarily committed foreither outpatient or inpatient care, or some otherbehavior or event that you know happens when youno longer have capacity to make mental healthdecisions, or you can specify that you want an eval-uation for incapacity.

If you do not choose a condition, your incapacitywill be determined after examination by a psychia-trist and one of the following: another psychiatrist,psychologist, family physician, attending physician,or other mental health treatment professional. Ifyou have doctors that you would prefer to make theevaluation, you should specify them in your Powerof Attorney. Although that doctor may not be avail-able, an effort will at least be made to contact them.

Until your condition is met, or you are found to beunable to make mental health decisions, you willmake decisions for yourself.

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V. POWER OF ATTORNEY

D. Authority granted to your Mental Health CareAgentYou may grant full power and authority to youragent to make all of your mental health care deci-sions, or you can set limits on the kinds of deci-sions your agent may make on your behalf. If youwish to limit the decisions your agent can makeyou should read each subsection carefully. Ifthere is some other mental health care decisionthat you do not want your agent to be able tomake, you may write it in. Pennsylvania law doesnot allow your agent to consent to psychosurgeryor the termination of parental rights on yourbehalf, even if you are willing for your agent tohave that power.

1. Treatment preferencesRemember that consenting in advance to aparticular medication or treatment does notmean your doctor will prescribe that treatmentor drug unless it is appropriate treatment at thetime you are ill. Consent only means that youconsent if it is a suitable choice at that timewithin the standards of medical care. Yourdoctor will also have to consider if a particulartreatment option is covered by your insurance.If, for example, the HMO that you have doesnot cover a certain drug on its formulary, yourdoctor may prescribe a drug that is similar, butis on the HMO formulary as long as you havenot withheld consent to that particular drug.

Although you do not have to explain yourchoices, it is helpful if you include statementsexplaining why you want or don’t want anyspecific treatments. If you do not have a prefer-ence in a given section, you may leave it blank.

a. Choice of Treatment FacilityIf you have a preference for, or bad feel-ings toward, any particular hospital, listthem here. Unfortunately, there are timeswhen a particular place is already full andwould be unable to accommodate you, orthe treating doctor does not have privi-leges at the hospital you would prefer.Therefore, although your doctor will try torespect your choice, it may not always bepossible.

b. Preferences regarding medicationsIf you give instructions about medications,

be sure to give reasons for your decisions.If, for instance, you experienced unaccept-able side effects from a particular genericor dose, you would want to be specific sothat your treating doctor understands yourconcern. That way your doctor will beless likely to prescribe something else thatis likely to cause similar problems.Likewise, if you know that a specificmedication has worked for you in the past,you should be sure to include that infor-mation. If a time-released version works,but the regular brand does not, you shouldbe sure you include that information. Themore your doctor knows about you, themore likely you are to get the right treat-ment, faster.

Be careful what you specify. Medicationscome in brand and generic names, andalso belong to broader classes of drugs,such as “atypical antipsychotics” or“SSRIs.” If you rule out an entire class ofdrugs, you should be aware that a new,helpful drug may come on the market thatcould be ruled out, even though you don’tactually know anything about it.

Giving your agent authority to make med-ication decisions allows more flexibility todeal with future situations. For instance,a new drug may come on the market thatis not currently available. By allowingyour agent to make the decision at thetime of your incapacity means that youragent will have the most up-to-date infor-mation on which to base decisions.

c. Preferences regarding electroconvulsivetherapy (ECT)In some cases, a doctor may find that ECTwould be an effective form of treatment. Ifyou have found ECT helpful in the past,and/or you trust your agent to make thatdecision if your doctor thinks it may help,you should initial the line next to “myagent is authorized to consent to the admin-istration of electroconvulsive therapy.”

If you do not wish to undergo ECT underany circumstances, you should initial theline next to “I do not consent to the admin-

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istration of electroconvulsive therapy.”NOTE: Your agent MAY NOT consent toECT unless you initial this authorization.

d. Preferences for experimental studiesOpportunities may exist for you to partici-pate in experimental studies related to treat-ment of your illness. Sometimes these stud-ies provide more data that helps doctorsdetermine the cause or best practice for treat-ing an illness. Sometimes the studies arebased on the idea that a certain new treat-ment might help. If you participate in astudy, you may have access to a new treat-ment sooner than you would otherwise.However, there may be some level of riskinvolved. If you want to participate in astudy because your doctor believes that thepotential benefits to you outweigh the poten-tial risks, you should initial the first choice.

If you do not want to participate in experi-mental studies of any kind, under any cir-cumstances, you should initial the choicethat states that you do not consent. NOTE:Your agent MAY NOT consent to experi-mental studies unless you initial thisauthorization.

e. Preferences regarding drug trialsSimilarly, you may have the opportunity toparticipate in a trial related to new medica-tions. If you participate, you may haveaccess to a new drug sooner than youwould otherwise. However, there may berisks or side effects. If you want to partici-pate in a drug trial because your doctorbelieves that the potential benefits to yououtweigh the potential risks, you should ini-tial the first choice.

If you do not want to participate in a drugtrial of any kind, under any circumstances,you should initial the choice that statesyour agent does not have your authorizationto consent on your behalf.

f. Additional instructions or informationOne of the significant benefits of filling outan Advance Directive is that you are com-municating important information to your

doctor and people who support you. Thispart of your form allows you to provideinformation that may or may not be directlyrelated to your mental health treatment. Ifthere is other information that you wouldlike your doctor to know, you shouldinclude it here. You can attach an addition-al page to the form if there is not enoughroom to write everything you need to. Justbe sure that you print or type your state-ments, and try to make them as clear aspossible, to minimize confusion about whatyou want to happen. Again, if you do nothave a preference about something listed,just leave that particular section blank.

E. Revocations and AmendmentsRevocation means that you are canceling yourPower of Attorney. If you revoke your Power ofAttorney, your agent will no longer be representingyou, and your doctor will no longer have to followthe instructions that your agent gives. You maychange or revoke your Power of Attorney at anytime, as long as you have capacity to make mentalhealth decisions when you make the change or rev-ocation. You may revoke a specific instructionwithout revoking the entire document.

If you are currently under an involuntary commit-ment, and you want to change or revoke your Powerof Attorney, you will need to request an evaluationto determine if you are capable of making mentalhealth decisions. The evaluation will be done byboth a psychiatrist and another psychiatrist, psychol-ogist, family physician, attending physician or othermental health professional. If you are found to havethe capacity to make mental health decisions, youwill be able to revoke or change your Power ofAttorney, even though you are in the hospital.

You may revoke your Power of Attorney orally orin writing. It becomes effective as soon as youcommunicate your revocation to your treating doc-tor. It is best to make any changes or revocation inwriting, because then there is a clear record of yourwishes.

If you make a new Power of Attorney, you shouldbe sure to notify your doctor and support people thatyou have revoked the old one. Your Power ofAttorney will automatically expire two years from

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the date you made it, unless you are unable to makemental health decisions for yourself at the time itwould expire. In that case, it will remain in forceuntil you are able to make decisions for yourself.

To amend your Power of Attorney means that youmake changes to it. You may make changes at anytime, as long as you have capacity to make mentalhealth care decisions. Any changes must be madein writing and be signed and witnessed by two indi-viduals in the same way as the original document.Any changes will be effective as soon as thechanges are communicated to your attending physi-cian or other mental health care provider, either byyou, or a witness to your amendments.

F. TerminationYour Advance Directive will automatically expiretwo years from the date of execution, unless youhave been found incapable of making mentalhealth care decisions at the time the Directivewould expire. In that case, the Directive will con-tinue to be in force until you regain capacity.

G. Preference as to a court-appointed guardianIf you become incapacitated, it is possible that acourt may appoint a guardian to act on yourbehalf. Under the guardianship laws, you maynominate a guardian of your person for considera-tion by the court. The court will appoint yourguardian in accordance with your most recentnomination except for good cause or disqualifica-tion. If you wish to name someone in your Powerof Attorney, it is important that you talk to thatperson about whether they feel they can serve asyour guardian, because a court will not force themto serve. It is also important that you give that per-son a copy of your Power of Attorney and explainyour wishes regarding mental health treatment.

If the court appoints a guardian, that person willnot be able to terminate, revoke or suspend yourPower of Attorney unless you want them to beable to. In this section, you should decide whetheryou want a court appointed guardian to have thatpower. Even if you do not specify a person thatyou would want as a guardian, you can still speci-fy whether a person that is appointed by the courtis allowed to terminate, revoke or suspend yourPower of Attorney.

If the court-appointed guardian and your agentturn out to be different people, the court will givepreference to allowing your mental health careagent to continue making mental health care deci-sions as provided in your Directive, unless youspecify otherwise in your Directive. If, after thor-ough examination, the court decides to grant thepowers that you gave to an agent to the guardian,the guardian would still be bound by the sameobligations that your agent would have been.

H. ExecutionYou must sign and date your Mental HealthCare Power of Attorney in this section. If youare unable to sign for yourself, someone else maysign on your behalf. Your document must besigned and dated by you in the presence of twowitnesses. Each witness must be at least 18 yearsold. If you are unable to sign the document your-self, you may have someone else sign on yourbehalf, but that person may not also be a witness.

In order for your Power of Attorney to be effec-tive, you must be sure that the right people haveaccess to it. Be sure to give copies of this to yourmental health care provider, and anyone else thatmay be notified in the event that you are found notto have capacity to make mental health care deci-sions. Remember that if you cancel or change yourdocument you must let everyone know. It is agood idea to carry a card in your wallet to let peo-ple know that you have a Power of Attorney.

Please Note: The information in this documentis not intended to constitute legal advice applica-ble to specific factual situations. For specificadvice contact the Disability Rights Network ofPennsylvania (DRN) intake line at 1-800-692-7443 (voice) or 1-877-375-7139 (TDD).

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Attending physician A physician who has primary responsibility for the treatment andcare of the person making the Advance Directive.

Agent An individual named by a person in a Mental Health Care Power of Attorney who will make mental health care decisions on behalfof the person.

Amend To change or modify by adding or subtracting language.

Declaration A writing which expresses a person’s wishes and instructions formental health care or other subjects.

Execute To sign, date, and have the signature witnessed.

Mental Health Advance Directive A document that allows a person to make choices regarding mental health treatment known in the event that the person is incapacitated by his/her mental illness. In effect, the person isgiving or withholding consent to treatment before treatment isneeded.

Mental health care Any care, treatment, service or procedure to maintain, diagnose,treat, or provide for mental health, including any medication program and therapeutic treatment.

Mental health care provider A person who is licensed, certified or otherwise authorized by thelaws of Pennsylvania to provide mental health care.

Mental health treatment professional A person trained and licensed in psychiatry, social work, psychology, or nursing who has a graduate degree and clinicalexperience.

Power of Attorney A writing made by a person naming someone else to make mentalhealth care decisions on behalf of the person.

Revoke To cancel or end.

VI. GLOSSARY OF TERMS

The following pages contain sample forms that can be torn out andused (or duplicated.) For more information on these please see theresources listed in the Introduction (p. 3). All forms have been provided as a courtesy from the Disability Rights Network ofPennsylvania.

FormsCombined Declaration Power of Attorney

Part I. IntroductionI,___________________________________________, having capacity to make mental health decisions,willfully and voluntarily make this Declaration and Power of Attorney regarding my mental health care. Iunderstand that mental health care includes any care, treatment, service or procedure to maintain, diagnose,treat or provide for mental health, including any medication program and therapeutic treatment.Electroconvulsive therapy may be administered only if I have specifically consented to it in this document. Iwill be the subject of laboratory trials or research only if specifically provided for in this document. Mentalhealth care does not include psychosurgery or termination of parental rights. I understand that my incapacitywill be determined by examination by a psychiatrist and one of the following: another psychiatrist, psychol-ogist, family physician, attending physician or mental health treatment professional. Whenever possible, oneof the decision makers will be one of my treating professionals.

A. When this Combined Mental Health Declaration and Power of Attorney becomes effective

This Combined Mental Health Declaration and Power of Attorney becomes effective at the following designated time:

■■ When I am deemed incapable of making mental health care decisions. I would prefer the following doctor(s) to evaluate me for my ability to make mental health decisions:

Name of Doctor: ______________________________________________________________________

Address/Phone Number: ________________________________________________________________

■■ When the following condition is met: (List condition) _____________________________________

B. Revocation and Amendments

This Combined Mental Health Care Declaration and Power of Attorney may be revoked in whole or inpart at any time, either orally or in writing, as long as I have not been found to be incapable of makingmental health decisions. My revocation will be effective upon communication to my attending physicianor other mental health care provider, either by me or a witness to my revocation, of the intent to revoke. IfI choose to revoke a particular instruction contained in this Power of Attorney in the manner specified, Iunderstand that the other instructions contained in this Power of Attorney will remain effective until:(1) I revoke this Power of Attorney in its entirety;(2) I make a new combined Mental Health Care Declaration and Power of Attorney; or(3) Two years from the date this document was executed.

I may make changes to this Advance Directive at any time, as long as I have capacity to make mental health caredecisions. Any changes will be made in writing and be signed and witnessed by two individuals in the same wayas the original document. Any changes will be effective as soon the changes are communicated to my attendingphysician or other mental health care provider, either by me, my agent, or a witness to my amendments.

C. Termination

I understand that this Declaration will automatically terminate two years from the date of execution, unless Iam deemed incapable of making mental health care decisions at the time that this Declaration would expire.

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COMBINED MENTAL HEALTH CARE DECLARATION AND POWER OF ATTORNEY FORM

Part II. Mental Health DeclarationA. Treatment preferences

1. Choice of treatment facility

■■ In the event that I require commitment to a psychiatric treatment facility, I would prefer to be admittedto the following facility:

Name of facility: _______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

■■ In the event that I require commitment to a psychiatric treatment facility, I do not wish to be committed to the following facility:

Name of facility: _______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

I understand that my physician may have to place me in a facility that is not my preference.

2. Preferences regarding medications for psychiatric treatment

■■ I consent to the medications that my treating physician recommends.

■■ I consent to the medications that my treating physician recommends with the following exceptions,limitations, and/or preferences:

Medication Reason for Exception ________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________

I consent to the following medications with these limitations:

Medication Limitation Reason for Limitation ________________________ ___________________ _______________________________________________________________ ___________________ _______________________________________________________________ ___________________ _______________________________________

I prefer the following medications:

Medication Reason for Preference ________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________

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The exception, limitation, or preference, applies to generic, brand name and trade name equivalentsunless otherwise stated. I understand that dosage instructions are not binding on my physician.

■■ I have designated an agent under the Power of Attorney portion of this document to make decisionsrelated to medication.

■■ I do not consent to the use of any medications.

3. Preferences for electroconvulsive therapy (ECT)

■■ I consent to the administration of electroconvulsive therapy.

■■ I have designated an agent under the Power of Attorney portion of this document to make decisionsrelated to electroconvulsive therapy.

■■ I do not consent to the administration of electroconvulsive therapy.

4. Preferences for experimental studies

■■ I consent to participation in experimental studies if my treating physician believes that the potentialbenefits to me outweigh the possible risks to me.

■■ I have designated an agent under the Power of Attorney portion of this document to make decisionsrelated to experimental studies.

■■ I do not consent to participation in experimental studies.

5. Preferences for drug trials.

■■ I consent to participation in drug trials if my treating physician believes that the potential benefits tome outweigh the possible risks to me.

■■ I have designated an agent under the Power of Attorney portion of this document to make decisionsrelated to drug trials.

■■ I do not consent to participation in any drug trials.

6. Additional instructions or information.

Examples of other instructions or information that may be included:Activities that help or worsen symptoms:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Type of intervention preferred in the event of a crisis:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Mental and physical health history:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dietary requirements:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Religious preferences:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary custody of children:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family notification:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Limitations on the release or disclosure of mental health records:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary care and custody of pets:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other matters of importance:_____________________________________________________________________________________

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_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part III. Mental Health Care Power of AttorneyI,___________________________________________, having the capacity to make mental health deci-sions, authorize my designated health care agent to make certain decisions on my behalf regarding mymental health care. If I have not expressed a choice in this document or in the accompanying Declaration,I authorize my agent to make the decision that my agent determines is the decision I would make if Iwere competent to do so.

A. Designation of agent

I hereby designate and appoint the following person as my agent to make mental health care decisions forme as authorized in this document. This authorization applies only to mental health decisions that are notaddressed in the accompanying signed Declaration.

Name of designated person: _____________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: __________________________________________________________________

Phone Number: __________- __________- _____________

Agent's acceptance:

I hereby accept designation as mental health care agent for (insert name of declarant).

________________________________________________________ .

Agent's signature: ______________________________________________________________________

Name of Agent: ________________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

B. Designation of alternative agent

In the event that my first agent is unavailable or unable to serve as my mental health care agent, I herebydesignate and appoint the following individual as my alternative mental health care agent to make mentalhealth care decisions for me as authorized in this document:

Name of designated person: ______________________________________________________________

Address: _____________________________________________________________________________

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City, State, Zip Code:____________________________________________________________________

Phone Number: __________- __________- _____________

Alternative Agent's acceptance:I hereby accept designation as alternative mental health care agent for (insert name of declarant).

________________________________________________________ .

Alternate Agent's signature: ______________________________________________________________

Name of Alternate Agent: ________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

C. Authority granted to my mental health care agent

I hereby grant to my agent full power and authority to make mental health care decisions for me consis-tent with the instructions and limitations set forth in this document. If I have not expressed a choice in thisPower of Attorney, or in the accompanying Declaration, I authorize my agent to make the decision thatmy agent determines is the decision I would make if I were competent to do so.

1. Preferences regarding medications for psychiatric treatment.

■■ My agent is authorized to consent to the use of any medications after consultation with my treatingpsychiatrist and any other persons my agent considers appropriate.

■■ My agent is not authorized to consent to the use of any medications.

2. Preferences regarding electroconvulsive therapy (ECT).

■■ My agent is authorized to consent to the administration of electroconvulsive therapy.

■■ My agent is not authorized to consent to the administration of electroconvulsive therapy.

3. Preferences for experimental studies.

■■ My agent is authorized to consent to my participation in experimental studies if, after consultationwith my treating physician and any other individuals my agent deems appropriate, my agent believesthat the potential benefits to me outweigh the possible risks to me.

■■ My agent is not authorized to consent to my participation in experimental studies.

4. Preferences regarding drug trials.

■■ My agent is authorized to consent to my participation in drug trials if, after consultation with my treat-ing physician and any other individuals my agent deems appropriate, my agent believes that the poten-tial benefits to me outweigh the possible risks to me.

■■ My agent is not authorized to consent to my participation in drug trials.

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PART IV. Nominating a GuardianA. Preference as to a court-appointed guardian

I understand that I may nominate a guardian of my person for consideration by the court if incapacityproceedings are commenced under 20 Pa.C.S. § 5511. I understand that the court will appoint a guardianin accordance with my most recent nomination except for good cause or disqualification. In the event acourt decides to appoint a guardian, I desire the following person to be appointed:

Name of Person: ______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code:___________________________________________________________________

Phone Number: __________- __________- _____________

■■ The appointment of a guardian of my person will not give the guardian the power to revoke, suspendor terminate this Combined Mental Health Care Declaration and Power of Attorney.

■■ Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate thisCombined Mental Health Care Declaration and Power of Attorney.

PART V. ExecutionI am making this Combined Mental Health Care Declaration and Power of Attorney on the

________ day of _____________, _______________.month year

My Signature: _______________________________________________________________________

My Name: __________________________________________________________________________

Address: ___________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number: __________- __________- _____________

_______________________________________ __________________________________________Witness Signature Witness Signature

Name of Witness: ____________________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number: __________- __________- _____________

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Name of Witness: _______________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ____________________________________________________________________

Phone Number: __________- __________- _____________

If the principal making this Combined Mental Health Care Declaration and Power of Attorney is unable tosign this document, another individual may sign on behalf of and at the direction of the principal. Anagent or a person signing on behalf of the principal may not also be a witness.

Signature of person signing on my behalf: ___________________________________________________

Name of Person:________________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

Disability Rights Network of Pennsylvania 2008. All Rights Reserved.

34

I,___________________________________________, having capacity to make mental health decisions,willfully and voluntarily make this Declaration regarding my mental health care. I understand that men-tal health care includes any care, treatment, service or procedure to maintain, diagnose, treat or providefor mental health, including any medication program and therapeutic treatment. Electroconvulsive therapymay be administered only if I have specifically consented to it in this document. I will be the subject oflaboratory trials or research only if specifically provided for in this document. Mental health care doesnot include psychosurgery or termination of parental rights. I understand that my incapacity will bedetermined by examination by a psychiatrist and one of the following: another psychiatrist, psychologist,family physician, attending physician or mental health treatment professional. Whenever possible, one ofthe decision makers will be one of my treating professionals.

A. When this Declaration becomes effective

This Declaration becomes effective at the following designated time:

■■ When I am deemed incapable of making mental health care decisions. I would prefer the followingdoctor(s) to evaluate me for my ability to make mental health decisions:

Name of Doctor: ______________________________________________________________________

Address/Phone Number: ________________________________________________________________

■■ When the following condition is met: (List condition)_____________________________________

B. Treatment preferences

1. Choice of treatment facility.

■■ In the event that I require commitment to a psychiatric treatment facility, I would prefer to be admitted to the following facility:

Name of facility: _______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: __________________________________________________________________

■■ In the event that I require commitment to a psychiatric treatment facility, I do not wish to be committed to the following facility:

Name of facility: ______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: __________________________________________________________________

I understand that my physician may have to place me in a facility that is not my preference.

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MENTAL HEALTH CARE DECLARATION FORM

2. Preferences regarding medications for psychiatric treatment.

■■ I consent to the medications that my treating physician recommends.

■■ I consent to the medications that my treating physician recommends with the following exceptions,limitations and/or preferences:

Medication Reason for Exception

__________________________ _________________________________________________________

__________________________ _________________________________________________________

__________________________ _________________________________________________________

I consent to the following medications with these limitations:

Medication Limitation Reason for Limitation

_______________________ ___________________ ________________________________________

_______________________ ___________________ ________________________________________

_______________________ ___________________ ________________________________________

I prefer the following medications:

Medication Reason for Preference

__________________________ _________________________________________________________

__________________________ _________________________________________________________

__________________________ _________________________________________________________

The exception, limitation, or preference, applies to generic, brand name and trade name equivalents unlessotherwise stated. I understand that dosage instructions are not binding on my physician.

■■ I do not consent to the use of any medications.

3. Preferences regarding electroconvulsive therapy (ECT).

■■ I consent to the administration of electroconvulsive therapy.

■■ I do not consent to the administration of electroconvulsive therapy.

4. Preferences for experimental studies.

■■ I consent to participation in experimental studies if my treating physician believes that the potentialbenefits to me outweigh the possible risks to me.

■■ I do not consent to participation in experimental studies.

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5. Preferences for drug trials.

■■ I consent to participation in drug trials if my treating physician believes that the potential benefits tome outweigh the possible risks to me.

■■ I do not consent to participation in any drug trials.

6. Additional instructions or information.

Examples of other instructions or information that may be included:Activities that help or worsen symptoms:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Type of intervention preferred in the event of a crisis:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mental and physical health history:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dietary requirements:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Religious preferences:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary custody of children:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Family notification:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Limitations on the release or disclosure of mental health records:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary care and custody of pets:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other matters of importance:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

C. Revocation and Amendments

This Declaration may be revoked in whole or in part at any time, either orally or in writing, as long as Ihave not been found to be incapable of making mental health decisions. My revocation will be effectiveupon communication to my attending physician or other mental health care provider, either by me or awitness to my revocation, of the intent to revoke. If I choose to revoke a particular instruction contained in this Declaration in the manner specified, I understand that the other instructions contained in this Declaration will remain effective until:

(1) I revoke this Declaration in its entirety;(2) I make a new Mental Health Advance Directive; or (3) Two years after the date this document was executed.

I may make changes to this Advance Directive at any time, as long as I have capacity to make mentalhealth care decisions. Any changes will be made in writing and be signed and witnessed by two individu-als in the same way the original document was executed. Any changes will be effective as soon thechanges are communicated to my attending physician or other mental health care provider, either by me ora witness to my amendments.

D. Termination

I understand that this Declaration will automatically terminate two years from the date of execution, unless Iam deemed incapable of making mental health care decisions at the time that this Declaration would expire.

E. Preference as to a court-appointed guardian

I understand that I may nominate a guardian of my person for consideration by the court if incapacity proceedings are commenced under 20 Pa.C.S. § 5511. I understand that the court will appoint a guardian

38

in accordance with my most recent nomination except for good cause or disqualification. In the event acourt decides to appoint a guardian, I desire the following person to be appointed:

Name of Person: ______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code:___________________________________________________________________

Phone Number: __________- __________- _____________

■■ The appointment of a guardian of my person will not give the guardian the power to revoke, suspendor terminate this Declaration.

■■ Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate this Declaration.

F. Execution

I am making this Declaration on the ________ day of _____________, _______________.month year

My Signature: _______________________________________________________________________

My Name: __________________________________________________________________________

Address: ___________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number: __________- __________- _____________

_______________________________________ __________________________________________Witness Signature Witness Signature

Name of Witness: ____________________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number: __________- __________- _____________

Name of Witness:_______________________________________________________________________

Address:______________________________________________________________________________

City, State, Zip Code:____________________________________________________________________

Phone Number: __________- __________- _____________

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If the principal making this Declaration is unable to sign it, another individual may sign on behalf of andat the direction of the principal.

Signature of person signing on my behalf: ___________________________________________________

Name of Person:________________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

Disability Rights Network of Pennsylvania 2008. All Rights Reserved.

40

I,___________________________________________, having the capacity to make mental health deci-sions, authorize my designated health care agent to make certain decisions on my behalf regarding mymental health care. If I have not expressed a choice in this document, I authorize my agent to make thedecision that my agent determines is the decision I would make if I were competent to do so.

I understand that mental health care includes any care, treatment, service or procedure to maintain, diag-nose, treat or provide for mental health, including any medication program and therapeutic treatment.Electroconvulsive therapy may be administered only if I have specifically consented to it in this docu-ment. I will be the subject of laboratory trials or research only if specifically provided for in this docu-ment. Mental health care does not include psychosurgery or termination of parental rights.

I understand that my incapacity will be determined by examination by a psychiatrist and one of the follow-ing: another psychiatrist, psychologist, family physician, attending physician or mental health treatmentprofessional. Whenever possible, one of the decision makers shall be one of my treating professionals.

A. Designation of agent

I hereby designate and appoint the following person as my agent to make mental health care decisions forme as authorized in this document.

Name of designated person: _____________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip Code: __________________________________________________________________

Phone Number: __________- __________- _____________

Agent's acceptance:

I hereby accept designation as mental health care agent for (insert name of declarant).

____________________________________________________________________________________ .

Agent's signature: ____________________________________________________________________

B. Designation of alternative agent

In the event that my first agent is unavailable or unable to serve as my mental health care agent, I herebydesignate and appoint the following individual as my alternative mental health care agent to make mentalhealth care decisions for me as authorized in this document:

Name of designated person: _____________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip Code: __________________________________________________________________

Phone Number: __________- __________- _____________

41

MENTAL HEALTH POWER OF ATTORNEY

Alternative Agent's acceptance:

I hereby accept designation as alternative mental health care agent for (insert name of declarant).

____________________________________________________________________________________ .

Alternate Agent's signature: _____________________________________________________________

C. When this Power of Attorney becomes effective

This Power of Attorney will become effective at the following designated time:

■■ When I am deemed incapable of making mental health care decisions. I would prefer the followingdoctor(s) to evaluate me for my ability to make mental health decisions:

Name of Doctor: _______________________________________________________________

Address/Phone Number: _________________________________________________________

■■ When the following condition is met: ____________________________________________

D. Authority granted to my mental health care agent

I hereby grant to my agent full power and authority to make mental health care decisions for me consis-tent with the instructions and limitations set forth in this Power of Attorney. If I have not expressed achoice in this Power of Attorney, I authorize my agent to make the decision that my agent determines isthe decision I would make if I were competent to do so.

1. Treatment preferences.

(a). Choice of treatment facility.

■■ In the event that I require commitment to a psychiatric treatment facility, I would prefer to be admittedto the following facility:

Name of facility: _______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

■■ In the event that I require commitment to a psychiatric treatment facility, I do not wish to be committedto the following facility:

Name of facility: _______________________________________________________________________

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

I understand that my physician may have to place me in a facility that is not my preference.

(b). Preferences regarding medications for psychiatric treatment.

■■ I consent to the medications that my agent agrees to after consultation with my treating physician andany other persons my agent considers appropriate.

42

■■ I consent to the medications that my agent agrees to, with the following exceptions or limitations:

Medication Reason for Exception

__________________________ _________________________________________________________

__________________________ _________________________________________________________

__________________________ _________________________________________________________

I consent to the following medications with these limitations:

Medication Limitation Reason for Limitation

_______________________ ___________________ ________________________________________

_______________________ ___________________ ________________________________________

_______________________ ___________________ ________________________________________

The exception or limitation applies to generic, brand name and trade name equivalents unless otherwisestated. I understand that dosage instructions are not binding on my physician.

■■ My agent is not authorized to consent to the use of any medications.

(c). Preferences regarding electroconvulsive therapy (ECT).

■■ My agent is authorized to consent to the administration of electroconvulsive therapy.NOTE: Your agent MAY NOT consent to ECT unless you initial this authorization.

■■ My agent is not authorized to consent to the administration of electroconvulsive therapy.

(d). Preferences for experimental studies.

■■ My agent is authorized to consent to my participation in experimental studies if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believesthat the potential benefits to me outweigh the possible risks to me.NOTE: Your agent MAY NOT consent to experimental studies unless you initial this authorization.

■■ My agent is not authorized to consent to my participation in experimental studies.

(e). Preferences regarding drug trials.

■■ My agent is authorized to consent to my participation in drug trials if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believes that thepotential benefits to me outweigh the possible risks to me.NOTE: Your agent MAY NOT consent to research including drug trials unless you initial thisauthorization.

■■ My agent is not authorized to consent to my participation in drug trials.

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(f). Additional instructions or information.

Examples of other instructions or information that may be included:

Activities that help or worsen symptoms:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Type of intervention preferred in the event of a crisis:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mental and physical health history:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dietary requirements:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Religious preferences:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary custody of children:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family notification:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

44

Limitations on the release or disclosure of mental health records:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Temporary care and custody of pets:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other matters of importance:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. Revocation and Amendments

This Power of Attorney may be revoked in whole or in part at any time, either orally or in writing, aslong as I have not been found to be incapable of making mental health decisions. My revocation will beeffective upon communication to my attending physician or other mental health care provider, either byme or a witness to my revocation, of the intent to revoke. If I choose to revoke a particular instructioncontained in this Power of Attorney in the manner specified, I understand that the other instructions con-tained in this Power of Attorney will remain effective until:

(4) I revoke this Power of Attorney in its entirety;(5) I make a new combined Mental Health Care Declaration and Power of Attorney; or(6) Two years from the date this document was executed.

I may make changes to this Power of Attorney at any time, as long as I have capacity to make mentalhealth care decisions. Any changes will be made in writing and be signed and witnessed by two individ-uals in the same way the original document was executed. Any changes will be effective as soon thechanges are communicated to my attending physician or other mental health care provider, either by me,my agent, or a witness to my amendments.

F. Termination

I understand that this Power of Attorney will automatically terminate two years from the date of execu-tion unless I am deemed incapable of making mental health care decisions at the time that the Power ofAttorney would expire.

G. Preference as to a court-appointed guardian

I understand that I may nominate a guardian of my person for consideration by the court if incapacityproceedings are commenced under 20 Pa.C.S. § 5511. I understand that the court will appoint a guardianin accordance with my most recent nomination except for good cause or disqualification. In the event acourt decides to appoint a guardian, I desire the following person to be appointed:

Name of Person: ______________________________________________________________________

Address: _____________________________________________________________________________

45

City, State, Zip Code:____________________________________________________________________

Phone Number: __________- __________- _____________

■■ The appointment of a guardian of my person will not give the guardian the power to revoke, suspendor terminate this Power of Attorney.

■■ Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate this Power of Attorney.

H. Execution

I am making this Mental Health Care Power of Attorney on the

________ day of _____________, _______________.month year

Principle Signature:______________________________________________________________________

Name of Principle: ______________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

_______________________________________ ____________________________________________Witness Signature Witness Signature

Name of Witness: ______________________________________________________________________

Address: ______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

Name of Witness:_______________________________________________________________________

Address:_______________________________________________________________________________

City, State, Zip Code:____________________________________________________________________

Phone Number: __________- __________- _____________

46

If the principal making this Mental Health Care Power of Attorney is unable to sign this document, another individual may sign on behalf of and at the direction of the principal.

Signature of person signing on my behalf: ___________________________________________________

Name of Person:________________________________________________________________________

Address:______________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Phone Number: __________- __________- _____________

Disability Rights Network of Pennsylvania 2008. All Rights Reserved.

47

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