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Washington Mental Health Advance Directive Form

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Washington Mental Health Advance Directive Form
Washington Mental Health Advance Directive Form
Mental Health Advance Directive
Page 1
NOTICE TO PERSONS
CREATING A MENTAL HEALTH ADVANCE DIRECTIVE
This is an important legal document. It creates an advance directive for mental health
treatment. Before signing this document you should know these important facts:
(1) This document is called an advance directive and allows you to make decisions in
advance about your mental health treatment, including medications, short-term
admission to inpatient treatment and electroconvulsive therapy.
YOU DO NOT HAVE TO FILL OUT OR SIGN THIS FORM.
IF YOU DO NOT SIGN THIS FORM, IT WILL NOT TAKE EFFECT.
If you choose to complete and sign this document, you may still decide to leave some
items blank.
(2) You have the right to appoint a person as your agent to make treatment decisions
for you. You must notify your agent that you have appointed him or her as an agent.
The person you appoint has a duty to act consistently with your wishes made known by
you. If your agent does not know what your wishes are, he or she has a duty to act in
your best interest. Your agent has the right to withdraw from the appointment at any
time.
(3) The instructions you include with this advance directive and the authority you give
your agent to act will only become effective under the conditions you select in this
document. You may choose to limit this directive and your agent's authority to times
when you are incapacitated or to times when you are exhibiting symptoms or behavior
that you specify. You may also make this directive effective immediately. No matter
when you choose to make this directive effective, your treatment providers must still
seek your informed consent at all times that you have capacity to give informed
consent.
(4) You have the right to revoke this document in writing at any time you have capacity.
YOU MAY NOT REVOKE THIS DIRECTIVE WHEN YOU HAVE BEEN FOUND TO BE
INCAPACITATED UNLESS YOU HAVE SPECIFICALLY STATED IN THIS
DIRECTIVE THAT YOU WANT IT TO BE REVOCABLE WHEN YOU ARE
INCAPACITATED.
(5) This directive will stay in effect until you revoke it unless you specify an expiration
date. If you specify an expiration date and you are incapacitated at the time it expires, it
will remain in effect until you have capacity to make treatment decisions again unless
you chose to be able to revoke it while you are incapacitated and you revoke the
directive.
Washington Mental Health Advance Directive Form
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