Mental Health Advance Directive

NC General Statute 122C-77 Statutory Form For Mental Health Treatment

An advance instruction/ directive which became effective January 1, 1998 allows you to make a legal directive in the case of mental health treatment. This advance instruction is binding for twenty four months(2 years) from the date that you specify your wishes to your physician. This is the only advance directive that requires periodic renewal. This document goes into effect when your doctor or mental health provider determines that you no longer understand the nature and consequences of proposed mental health treatment and that you cannot make decisions about that treatment. This document must be signed by you (or have someone sign the document in your presence and at your direction, if you are unable to sign). The signatures on this document must be witnessed by 2 qualified* adults, dated, and notarized.

The directive for mental health treatment allows you to make treatment and medication decisions if you should require admission to and retention in a facility for the care or treatment of mental illness. This directive allows you to further clarify your wishes in regard to mental health care and treatment. For more information regarding advance directives please contact: Marcus Dodson, M. Div, T.C.H. Chaplain at (828) 883-5497, or Transylvania Regional Hospital's Admissions Department at (828) 884-9111

Advance Instruction for Mental Health

I,_______________________________ , being an adult of sound mind, willfully and voluntarily make this advance instruction for mental health treatment to be followed if it is determined by a physician or eligible psychologist 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. `Mental health treatment' means the process of providing for the physical, emotional, psychological, and social needs of the principal. `Mental health treatment' includes electroconvulsive treatment needs of the principal. `Mental health treatment' includes electroconvulsive treatment (ECT), commonly referred to as `shock treatment' treatment of mental illness with psychotropic medication, and admission to and retention in a facility for care or treatment of mental illness.

I understand that psychoactive medications and electroconvulsive treatment (ECT) (commonly referred to as `shock treatment') may not be administered without my express and informed written consentor, if I am incapable of giving my informed consent, the express and informed consent of my legally responsible person, health care agent named pursuant to a valid health care power of attorney, or attorney-in-fact named pursuant to a valid advance instruction for mental health treatment, as required under G.S. 122C-57.

I understand that I may become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder. These symptoms may include:

_______________________________________________________________________

_______________________________________________________________________

Psychoactive Medications

If I become incapable of giving or withholding informed consent for mental health treatment, my instructions regarding psychoactive medications are as follows:

I consent to the administration of the following medications: _____________________________

_______________________________________________________________________

I do not consent to the administration of the following medications: ____________________

_______________________________________________________________________

Conditions or limitations: ____________________________________________________

Admission To and Retention in Facility

If I become incapable of giving or withholding informed consent for mental health treatment, my instructions regarding admission to and retention in a health care facility for mental health treatment are as follows:

_______I consent to being admitted to a health care facility for mental health treatment.

My facility preference is ____________________________________________________

_______I do not consent to being admitted to a health care facility for mental health treatment.
This advance instruction cannot, by law, provide consent to retain me in a facility for more than 10 days.

Conditions or limitations: ________________________________________________

_______________________________________________________________________

Additional Instructions:

These instructions shall apply during the entire length of my incapacity. In case of mental health crisis, please contact:

1.
Name: ________________________________________________________________

Home Address:__________________________________________________________

Home Telephone Number:_________________ Work Telephone Number:____________

Relationship to Me:_______________________________________________________

2.
Name: ________________________________________________________________

Home Address:__________________________________________________________

Home Telephone Number:_________________ Work Telephone Number:____________

Relationship to Me:_______________________________________________________

3.
My Physician: ___________________________________________________________

Name: ________________________________ Telephone Number: _________________

4.
My Therapist: Name: ______________________________________________________

Name: ________________________________ Telephone Number: _________________

The following may cause me to experience a mental health crisis:_______________________

_______________________________________________________________________

The following may help me avoid hospitalization: __________________________________

_______________________________________________________________________

I generally react to being hospitalized as follows: __________________________________

_______________________________________________________________________

Staff of the hospital or crisis unit can help me by doing the following: ___________________

_______________________________________________________________________

I give permission for the following person or people to visit me: _______________________

_______________________________________________________________________

Instructions concerning any other medical interventions, such as electroconvulsive (ECT) treatment

(commonly referred to as `shock treatment'): ____________________________________

_______________________________________________________________________

_______________________________________________________________________

Other instructions: _________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

___________ I have attached an additional sheet of instructions to be followed and considered part of this advance instruction.

Attorney-In-Fact

I hereby appoint: Name: ___________________________________________________

Home address: __________________________________________________________

Home Telephone Number: ________________ Work Telephone Number: _____________ 
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: _________________________________________________________________

Home address: __________________________________________________________

Home Telephone Number: ________________ Work Telephone Number: _____________

My attorney-in-fact is authorized to make decisions that are consistent with the instructions that I have expressed in this advance instruction or, if not expressed, as are otherwise known by my attorney-in-fact, is to act in what he or she believes to be my best interests. If it becomes necessary for the court to appoint a guardian for me, I hereby nominate my attorney-in-fact to serve in that capacity By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my attorney-in-fact.

________________________________________________ ___________________
Signature of Principal Date

Affirmation of Witnesses

We affirm that the principal is personally known to us, that the principal signed or acknowledged the principal's signature on this advance instruction for mental health treatment in our presence, tat the principal appears to be of sound mind and not under duress, fraud or undue influence, and that neither of us is:

* A person appointed as an attorney-in-fact by this document:
* The principal's attending physician or mental health service provider or a relative of the physician or provider:
*the owner, operator, or relative of an owner or operator of a facility in which the principal is a patient or resident; or
* A person related to the principal by blood, marriage, or adoption.

Witnessed by:

________________________________________________ _________________ Witness Date

 

________________________________________________ _________________ Witness Date

State of North Carolina, County of ____________________________________-

Acceptance of Appointment of Attorney-In-Fact

I accept this appointment and agree to serve as attorney-in-fact to make decisions about mental health treatment for the principal. I understand that I have a duty to act consistent with the desires of the principal as expressed in this appointment. I understand that this document gives me authority to make decisions about mental health treatment only when the principal is incapable as determined by a qualified crisis services professional and a physician or eligible psychologist. I understand that the principal may revoke this advance instruction in whole or in part at any time and in any manner when the principal is not incapable.

______________________________________________ _____________________
Signature of Attorney-in-fact Date

______________________________________________ _____________________
Signature of Alternative Attorney-in-fact Date

Section 3. G.S. 122C-57 reads as rewritten: "§ 122C-57. Right to treatment and consent to treatment.

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