Who is Agent?

• Indicate the full name of an appointed agent:

  !

  An agent is an individual whom you appoint to make mental health care decisions on your behalf.

• Indicate the full residential address of the agent:

• Provide the agent's contact phone number:

• Do you want to appoint an alternative agent?

  • No
  • Yes

  !

  An alternative agent is a person authorized to make mental health care decisions on your behalf if the primary agent is unable or unwilling to serve, or if they resign.

• Indicate the alternative's agent full name:

• Indicate the residential address of an alternative agent:

• Indicate the alternative's agent contact phone number:

Power of Attorney Details

• This power of attorney becomes effective when:

  • Principal becomes mentally incapable
  • Other event(s)

• Provide a detailed description of the event or events that will trigger this power of attorney to become effective:

• If a court appoints a guardian, provide the full name, date of birth, and contact information of the individual the principal prefers for this role:

  !

  A guardian is a person appointed by the court to make decisions about the individual’s personal care, living arrangements, and sometimes medical treatment.

  Unlike the agent named in the power of attorney, a guardian is typically imposed by the court when no valid agent is available or when additional oversight is needed.

• Shall the appointed guardian have the authority to cancel this power of attorney?

  • No
  • Yes

Medical Treatments

• Provide the full name and address of the medical facility where the principal prefers all treatments to be administered:

• Does the principal consent to participation in experimental psychiatric treatments or clinic trials?

  • No
  • Yes

• Does the principal consent to electroconvulsive therapy (ECT)?

  • No
  • Yes

• Does the principal consent to the use of medications for treatment of their mental health?

  • No, I do not allow usage of any medications
  • I consent to the usage of some medications
  • Yes

• List all medications to which the principal consents for use in their treatment:

• Are there any additional medical treatments to which the principal wishes to consent?

  • No
  • Yes

• List all the medical treatments to which the principal wishes to consent:

• Do you want to add a signature?

  • Yes
  • No

• Principal's signature:

  Save signature Clean

  Edit signature