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Declaration For Mental Health Treatment
**This declaration is available to execute in-person at Rogue Healing Collective.
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I, _______________________ ( your name) being an adult of sound
mind, willfully and voluntarily make this declaration for mental health treatment. I
want this declaration to be followed if a court or two physicians determine that I am
unable to make decisions for myself because 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. “Mental health
treatment” means treatment of mental illness with psychoactive medication,
admission to and retention in a health care facility for a period up to 17 days,
convulsive treatment and outpatient services that are specified in this declaration.
Choice of Decision Maker
If I become incapable of giving or withholding informed consent for mental health
treatment, I want these decisions to be made by:
-
My appointed representative, consistent with my desires, or, if my desires
are unknown by my representative, in what my representative believes to be
my best interests. -
By the mental health treatment provider who requires my consent in order
to treat me, but only as specifically authorized in this Declaration.
Appointed Representative
If I have chosen to appoint a representative to make mental health treatment
decisions for me when I am incapable, I am naming that person here. I may also
name an alternate representative to serve. Each person I appoint must accept my
appointment in order to serve. I understand that I am not required to appoint a
representative in order to complete this declaration.
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I hereby appoint the following to act as my representative to make decisions
regarding my mental health treatment if I become incapable of giving or
withholding informed consent for that treatment.
Name: ________________________________________________
Address:______________________________________________
Telephone number:__________________________________
(**OPTIONAL)
If the person named above refuses or is unable to act on my behalf, or if l revoke
that person’s authority to act
as my representative, I authorize the following person to act as my representative:
Name: ________________________________________________
Address:______________________________________________
Telephone number:__________________________________
My representative is authorized to make decisions that are consistent with the
wishes I have expressed in this declaration or, if not expressed, as are otherwise
known to my representative. If my desires are not expressed and are not otherwise
known by my representative, my representative is to act in what he or she believes
to be in my best interests. My representative is also authorized to receive
information regarding proposed mental health treatment and to receive, review
and consent to disclosure of medical records relating to that treatment.
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Directions for Mental Health Treatment
This declaration permits me to state my wishes regarding mental health treatments
including psychoactive medications, admission to and retention in a health are
facility for mental health treatment for a period not to exceed 17 days, convulsive
treatment and outpatient care services.
If I become incapable of giving or withholding informed consent for mental health
treatment, my wishes are:
-
I CONSENT TO THE FOLLOWING MENTAL HEALTH TREATMENTS: (May include
types and dosage of medications, short term inpatient treatment, a preferred
provider or facility, transport to a provider or facility, convulsive treatment or
alternative outpatient treatments.)________________________________________________ -
I DO NOT CONSENT TO THE FOLLOWING MENTAL HEALTH TREATMENT:
(Consider including your reasons, such as past adverse reaction, allergies or
misdiagnosis. Be aware that a person may be treated without consent if the
person is held pursuant to civil commitment law.)
__________________________________________________________
ADDITIONAL INFORMATION ABOUT MY MENTAL HEALTH TREATMENT NEEDS:
(Consider including mental or physical health history, dietary requirements,
religious concerns, people to notify and other matters of importance.)
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YOU MUST SIGN AND DATE HERE FOR THIS DECLARATION TO BE EFFECTIVE:
______________________ ___________
Signature Date
Affirmation of Witnesses
I affirm that the person signing this declaration:
a. Is personally known to me;
b. Signed or acknowledged his or her signature on this declaration in my
presence;
c. Appears to be sound mind and not under duress, fraud or undue
influence;
d. Is not related to me by blood, marriage or adoption;
e Is not a patient or resident in a facility that I or my relative owns or
operates;
f. Is not my patient and does not receive mental health services from me or
my relative; and
g. Has not appointed me as a representative in this document.
Witnessed by:
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_______________________ ____________________
Signature of Witness Printed name of Witness
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_______________________
Date
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Acceptance of Appointment As Representative
I accept this appointment and agree to serve as representative to make mental
health treatment decisions. I understand that I must act consistently with the
desires of the person I represent, as expressed in this declaration or, if not
expressed, as otherwise known by me. If I do not know the desires of the person I
represent, I have a duty to act in what I believe in good faith to be that person’s
best interest. I understand that this document gives me authority to make decisions
about mental health treatment only while that person has been determined to be
incapable of making those decisions by a court or two physicians. I understand that
the person who appointed me may revoke this declaration in whole or in part by
communicating the revocation to the attending physician or other provider when
the person is not incapable.
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_________________________ _______________________
Signature of Representative Printed name of Representative
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_________________________
Date
_________________________ _______________________
Signature of Alternate Representative Printed name of Alt. Representative
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_________________________
Date
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Notice to Person Making A Declaration for Mental Health Treatment
This is an important legal document. It creates a declaration for mental health
treatment. Before signing this document, you should know these important facts:
This document allows you to make decisions in advance about certain types of
mental health treatment:
psychoactive medication, short-term (not to exceed 17 days) admission to a
treatment facility, convulsive treatment and outpatient services. Outpatient services
are mental health services provided by appointment by licensed professionals and
programs. The instructions that you include in this declaration will be followed only
if a court or two physicians believe that you are incapable of making treatment
decisions. Otherwise, you will be considered capable to give or withhold consent for
the treatments. Your instructions may be overridden if you are being held pursuant
to civil commitment law.
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You may also appoint a person as your representative to make treatment decisions
for you if you become incapable. The person you appoint has a duty to act
consistently with your desires as stated in this document or, if not stated, as
otherwise known by the representative. If your representative does not know your
desires, he or she must make decisions in your best interests. For the appointment
to be effective, the person you appoint must accept the appointment in writing. The
person also has the right to withdraw from acting as your representative at any
time. A “representative” is also referred to as an “attorney-in-fact” in state law but
this person does not need to be an attorney at law.
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This document will continue in effect for a period of three years unless you become
incapable of participating in mental health treatment decisions. If this occurs, the
directive will continue in effect until you are no longer incapable.
You have the right to revoke this document in whole or in part at any time you have
not been determined to be incapable. YOU MAY NOT REVOKE THIS DECLARATION
WHEN YOU ARE CONSIDERED INCAPABLE BY A COURT OR TWO PHYSICIANS. A
revocation is effective when it is communicated to your attending physician or
other provider.
If there is anything in this document that you do not understand, you should ask a
lawyer to explain it to you. This declaration will not be valid unless it is signed by
two qualified witnesses who are personally known to you and who are present
when you sign or acknowledge your signature.
Notice to Physician or Provider
Under Oregon law, a person may use this declaration to provide consent for mental
health treatment or to appoint a representative to make mental health treatment
decisions when the person is incapable of making those decisions. A person is
“incapable” when, in the opinion of a court or two physicians, the person’s ability to
receive and evaluate information effectively or communicate decisions is impaired
to such an extent that the person currently lacks the capacity to make mental
health treatment decisions. This document becomes operative when it is delivered
to the person’s physician or other provider and remains valid until revoked or
expired. Upon being presented with this declaration, a physician or provider must
make it a part of the person’s medical record. When acting under authority of the
declaration, a physician or provider must comply with it to the fullest extent
possible. If the physician or provider is unwilling to comply with the declaration, the
physician or provider may withdraw from providing treatment consistent with
professional judgment and must promptly notify the person and the person’s
representative and document the notification in the person’s medical record. A
physician or provider who administers or does not administer mental health
treatment according to and in good faith reliance upon the validity of this
declaration is not subject to criminal prosecution, civil liability or professional
disciplinary action resulting from a subsequent finding of the declaration’s
invalidity.
This Guide to Oregon’s Declaration for Mental Health Treatment and Form was
developed pursuant to Oregon Revised Statutes (ORS) 127.700 through 127.736.
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