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§43A-11-106.
§43A-11-106.
A. A declaration stating the mental health treatment wishes of the
declarant executed in accordance with the provisions of this act shall
be substantially in the form provided by subsection E of this section.
B. A declarant may designate a capable person eighteen (18) years of
age or older to act as attorney-in-fact to make mental health
treatment decisions. An alternative attorney-in-fact may also be
designated to act as attorney-in-fact if the original attorney-in-fact
is unable or unwilling to act at any time. An appointment of an
attorney-in-fact shall be substantially in the form provided by
subsection E of this section.
C. An attorney-in-fact who has accepted the appointment in writing
shall have authority to make decisions, in consultation with the
attending physician or psychologist, about mental health treatment on
behalf of the declarant only when the declarant is certified as
incapable and to require mental health treatment as provided by
Section 10 of this act.
1. These decisions shall be consistent with any wishes or instructions
the declarant has expressed in the declaration. If the wishes or
instructions of the declarant are not expressed, the attorney-in-fact
shall act in what the attorney-in-fact believes to be in the best
interest of the declarant.
2. The attorney-in-fact may consent to inpatient mental health
treatment on behalf of the declarant if so authorized in the advance
directive for mental health treatment.
D. An attorney-in-fact may withdraw by giving notice to the declarant.
If a declarant is incapable, the attorney-in-fact may withdraw by
giving notice to the named alternative attorney-in-fact if any, and if
none then to the attending physician or provider. The attending
physician or provider shall note the withdrawal of the last named
attorney-in-fact as part of the declarant's medical record.
E. An advance directive for mental health treatment shall be notarized
and shall be in substantially the following form:
ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT
I, _____________________, being of sound mind and eighteen (18) years
of age or older, willfully and voluntarily make known my wishes about
mental health treatment, by my instructions to others through my
advance directive for mental health treatment, or by my appointment of
an attorney-in-fact, or both. I thus do hereby declare:
I. DECLARATION FOR MENTAL HEALTH TREATMENT
If my attending physician or psychologist and another physician or
psychologist determine that my ability to receive and evaluate
information effectively or communicate decisions is impaired to such
an extent that I lack the capacity to refuse or consent to mental
health treatment and that mental health treatment is necessary, I
direct my attending physician or psychologist and other health care
providers, pursuant to the Advance Directives for Mental Health
Treatment Act, to provide the mental health treatment I have indicated
below by my signature.
I understand that "mental health treatment" means convulsive
treatment, treatment with psychoactive medication, and admission to
and retention in a health care facility for a period up to
twenty-eight (28) days.
I direct the following concerning my mental health
care:___________________________________________________
________________________________________________________________
I further state that this document and the information contained in it
may be released to any requesting licensed mental health professional.
____________________________ ___________________
Declarant's Signature Date
____________________________ ___________________
Witness 1 Date
____________________________ ___________________
Witness 2 Date
II. APPOINTMENT OF ATTORNEY-IN-FACT
If my attending physician or psychologist and another physician or
psychologist determine that my ability to receive and evaluate
information effectively or communicate decisions is impaired to such
an extent that I lack the capacity to refuse or consent to mental
health treatment and that mental health treatment is necessary, I
direct my attending physician or psychologist and other health care
providers, pursuant to the Advance Directives for Mental Health
Treatment Act, to follow the instructions of my attorney-in-fact.
I hereby appoint:
NAME _____________________________________
ADDRESS __________________________________
TELEPHONE #_______________________________
to act as my attorney-in-fact to make decisions regarding my mental
health treatment if I become incapable of giving or withholding
informed consent for that treatment.
If the person named above refuses or is unable to act on my behalf, or
if I revoke that person's authority to act as my attorney-in-fact, I
authorize the following person to act as my attorney-in-fact:
NAME ______________________________________
ADDRESS ___________________________________
TELEPHONE #________________________________
My attorney-in-fact is authorized to make decisions which are
consistent with the wishes I have expressed in my declaration. If my
wishes are not expressed, my attorney-in-fact is to act in what he or
she believes to be my best interest.
_______________________________________
(Signature of Declarant/Date)
III. CONFLICTING PROVISION
I understand that if I have completed both a declaration and have
appointed an attorney-in-fact and if there is a conflict between my
attorney-in-fact's decision and my declaration, my declaration shall
take precedence unless I indicate otherwise.
____________________ ___________ (signature)
IV. OTHER PROVISIONS
a. In the absence of my ability to give directions regarding my mental
health treatment, it is my intention that this advance directive for
mental health treatment shall be honored by my family and physicians
or psychologists as the expression of my legal right to consent or to
refuse to consent to mental health treatment.
b. This advance directive for mental health treatment shall be in
effect until it is revoked.
c. I understand that I may revoke this advance directive for mental
health treatment at any time.
d. I understand and agree that if I have any prior advance directives
for mental health treatment, and if I sign this advance directive for
mental health treatment, my prior advance directives for mental health
treatment are revoked.
e. I understand the full importance of this advance directive for
mental health treatment and I am emotionally and mentally competent to
make this advance directive for mental health treatment.
Signed this _____ day of__________, 19 __
___________________________________
(Signature)
___________________________________
City, County and State of Residence
This advance directive was signed in my presence.
___________________________________
(Signature of Witness)
___________________________________
(Address)
___________________________________
(Signature of Witness)
___________________________________
(Address)
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