N.M. Stat. § 24-7B-7
"ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT
I, ______________________, being a person with capacity, 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 agent, or both. If a guardian or an agent is appointed to make mental health decisions for me, I intend this document to take precedence over other means of ascertaining my wishes and interests.
The fact that I may have left blanks in this directive does not affect its validity in any way. I intend that all completed sections be followed. I intend this directive to take precedence over any other mental health directives I have previously executed, to the extent that they are inconsistent with this document, or unless I expressly state otherwise in either document.
I understand that I may revoke this directive in whole or in part if I am a person with capacity. I understand that I cannot revoke this directive if one qualified health care professional and one mental health treatment provider find that I am an incapacitated person, unless I successfully challenge the determination of incapacity.
I understand there are some circumstances where my provider may not have to follow my directive, specifically, if the treatment requested in this directive is infeasible or unavailable, the facility or provider is not licensed or authorized to provide the treatment requested or the directive conflicts with other applicable law.
I thus do hereby declare:
If a mental health treatment provider and a qualified health care professional, one of whom is my primary health care professional, if reasonably available, 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 primary health care professional and a mental health treatment provider, pursuant to the Mental Health Care Treatment Decisions Act, to provide the mental health treatment I have indicated below by my signature.
I understand that "mental health treatment" means services provided for the prevention of, amelioration of symptoms of or recovery from mental illness or emotional disturbance, including but not limited to electroconvulsive treatment, treatment with medication, counseling, rehabilitation services or evaluation for admission to a facility for care or treatment of persons with mental illness, if required.
Preferences and Instructions About Treatment, Facilities and Physicians
I would like the physician(s) named below to be involved in my treatment decisions:
Dr. ____________________ Contact information __________________
Dr. ____________________ Contact information __________________
I do not wish to be treated by Dr. ____________________________
Other Preferences: ____________________________________________
Preferences and Instructions About Other Providers
I am receiving other treatment or care from providers who I feel have an impact on my mental health care. I would like the following treatment provider(s) to be contacted when this directive is effective:
Name: __________________ Profession: _____________________
Contact Information ______________________
Name: __________________ Profession: _____________________
Contact Information ______________________
Preferences and Instructions About Medications for Mental Health Treatment
(initial and complete all that apply)
____ I consent, and authorize my agent to consent, to the following medications:
______________________________________________________________________
____ I do not consent, and I do not authorize my agent to consent, to the administration of the following medications:
______________________________________________________________________
____ I am willing to take the medications excluded above if my only reason for excluding them is the side effects, which include _________________________________, and these side effects can be eliminated by dosage adjustment or other means.
____ I am willing to try any other medications the hospital doctor recommends.
____ I am willing to try any other medications my outpatient doctor recommends.
____ I do not want to try any other medications.
Medication Allergies
I have allergies to, or severe side effects from, the following:
______________________________________________________________________
I have the following other preferences or instructions about medications:
______________________________________________________________________
Preferences and Instructions About Hospitalization and Alternatives
(initial all that apply and, if desired, rank "1" for first choice, "2" for second choice, and so on)
____ In the event my psychiatric condition is serious enough to require 24-hour care and I have no physical conditions that require immediate access to emergency medical care, I prefer to receive this care in programs/facilities designed as alternatives to psychiatric hospitalization.
____ I would also like the interventions below to be tried before hospitalization is considered:
____ Calling someone or having someone call me when needed
Name: _________________ Telephone: _____________________
____ Having a mental health service provider come to see me
____ Going to a crisis triage center or emergency room
____ Staying overnight at a crisis respite (temporary) bed
____ Seeing a provider for help with psychiatric medications
____ Other, specify: ___________________________________________ Authority to Consent to Inpatient Treatment
I consent, and authorize my agent to consent, to evaluation for admission to inpatient mental health treatment.
(Sign one)
____ If deemed appropriate by my agent and treating physician
________________________________ Signature
or
____ Under the following circumstances (specify symptoms, behaviors or circumstances that indicate the need for hospitalization)
______________________________________________________________________
________________________________ Signature
____ I do not consent, or authorize my agent to consent, to evaluation for admission to inpatient treatment
________________________________ Signature
Preferences and Instructions About Use of Seclusion or Restraint
I would like the interventions below to be tried before use of seclusion or restraint is considered (initial all that apply)
____ "Talk me down": one-on-one
____ More medication
____ Time out/privacy
____ Show of authority/force
____ Shift my attention to something else
____ Set firm limits on my behavior
____ Help me to discuss/vent feelings
____ Decrease stimulation
____ Offer to have neutral person settle dispute
____ Other, specify __________________________________
If it is determined that I am engaging in behavior that requires seclusion, physical restraint and/or emergency use of medication, I prefer these interventions in the order I have chosen (choose "1" for first choice, "2" for second choice, and so on):
____ Seclusion
____ Seclusion and physical restraint (combined)
____ Medication by injection
____ Medication in pill or liquid form In the event my physician decides to use medication in response to an emergency situation after due consideration of my preferences and instructions for emergency treatments stated above, I expect the choice of medication to reflect any preferences and instructions I have expressed in this directive. The preferences and instructions I have expressed in this section regarding medication in emergency situations do not constitute consent to use of the medication for nonemergency treatment.
Preferences and Instructions About Electroconvulsive Therapy
My wishes regarding electroconvulsive therapy are (Sign one):
____ I do not consent, nor authorize my agent to consent, to the administration of electroconvulsive therapy.
________________________________ Signature
____ I consent, and authorize my agent to consent, to the administration of electroconvulsive therapy.
________________________________ Signature
____ I consent, and authorize my agent to consent, to the administration of electroconvulsive therapy, but only under the following conditions:
______________________________________________________________________
__________
________________________________ Signature
Preferences and Instructions About Who Is Permitted to Visit If I have been admitted to a mental health treatment facility, the following people are not permitted to visit me there:
Name: ________________________________________________________
Name: ________________________________________________________
Name: ________________________________________________________
I understand that persons not listed above may be permitted to visit me.
Additional Instructions About My Mental Health Care
Other instructions about my mental health care: ______________
In case of emergency, please contact: ________________________
Name: _____________________
Address: _____________________
Work Telephone: _____________________
Home telephone: ______________
Physician: _____________________
Address: _____________________
Telephone: _____________________
The following may help me to avoid a hospitalization:
______________________________________________________________________
I generally react to being hospitalized as follows:
______________________________________________________________________
Staff of the hospital or crisis unit can help me by doing the following:
______________________________________________________________________
Refusal of Treatment
I do not consent to any mental health treatment.
________________________________
Signature
I further state that this document and the information contained in it may be released to any requesting licensed mental health professional.
__________________________________ __________________________________
Signature of principal Date
__________________________________ __________________________________
Signature of witness Date
I hereby appoint:
Name ________________________________________
Address _____________________________________
Telephone _________________________________ to act as my agent 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 agent, I authorize the following person to act as my agent:
Name ________________________________________
Address _____________________________________
Telephone _________________________________ My agent is authorized to make decisions that are consistent with the wishes I have expressed in my declaration. If my wishes are not expressed, my agent is to act in what he or she believes to be my best interest.
_____________________________ _____________________________
Signature of principal Date
I understand that if I have completed both a declaration and have appointed an agent and if there is a conflict between my agent's decision and my declaration, my declaration shall take precedence unless I indicate otherwise.
________________________________ Signature
I understand that if I have completed both an advance health care directive and an advance directive for mental health treatment, that those directives should be executed as separate instructions.
________________________________ Signature
______________________________________________________________________
Signed this _______ day of ___________, 20__
__________________________________________
Signature
__________________________________________
City, county and state of residence
This advance directive was signed in my presence.
__________________________________________
Signature of witness
__________________________________________
Address.
__________________________________________ ."
NMS § 24-7B-7