20 Pa. C.S. § 5833
Mental Health Power of Attorney
I, , having the capacity to make mental health decisions, authorize my designated health care agent to make certain decisions on my behalf regarding my mental health care. If I have not expressed a choice in this document, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.
I understand that mental health care includes any care, treatment, service or procedure to maintain, diagnose, treat or provide for mental health, including any medication program and therapeutic treatment. Electroconvulsive therapy may be administered only if I have specifically consented to it in this document. I will be the subject of laboratory trials or research only if specifically provided for in this document. Mental health care does not include psychosurgery or termination of parental rights.
I understand that my incapacity will be determined by examination by a psychiatrist and one of the following: another psychiatrist, psychologist, family physician, attending physician or mental health treatment professional. Whenever possible, one of the decision makers shall be one of my treating professionals.
I hereby designate and appoint the following person as my agent to make mental health care decisions for me as authorized in this document:
(Insert name of designated person)
Signed:
(My name, address, telephone number)
(Witnesses' signatures)
(Names, addresses, telephone numbers of witnesses)
Agent's acceptance:
I hereby accept designation as mental health care agent for (Insert name of declarant)
Agent's signature:
(Insert name, address, telephone number of designated person)
In the event that my first agent is unavailable or unable to serve as my mental health care agent, I hereby designate and appoint the following individual as my alternative mental health care agent to make mental health care decisions for me as authorized in this document:
(Insert name of designated person)
Signed:
(Witnesses' signatures)
(Names, addresses, telephone numbers of witnesses)
Alternative agent's acceptance:
I hereby accept designation as alternative mental health care agent for
(Insert name of declarant)
Alternative agent's signature: .
(Insert name, address, telephone number)
This power of attorney will become effective at the following designated time:
( ) When I am deemed incapable of making mental health care decisions.
( ) When the following condition is met:
(List condition)
I hereby grant to my agent full power and authority to make mental health care decisions for me consistent with the instructions and limitations set forth in this power of attorney. If I have not expressed a choice in this power of attorney, I authorize my agent to make the decision that my agent determines is the decision I would make if I were competent to do so.
( ) In the event that I require commitment to a psychiatric treatment facility, I would prefer to be admitted to the following facility:
(Insert name and address of facility)
( ) In the event that I require commitment to a psychiatric treatment facility, I do not wish to be committed to the following facility:
(Insert name and address of facility)
I understand that my physician may have to place me in a facility that is not my preference.
( ) I consent to the medications that my agent agrees to after consultation with my treating physician and any other persons my agent considers appropriate.
( ) I consent to the medications that my agent agrees to, with the following exception or limitation:
(List exception or limitation)
This exception or limitation applies to generic, brand name and trade name equivalents.
( ) My agent is not authorized to consent to the use of any medications.
( ) My agent is authorized to consent to the administration of electroconvulsive therapy.
( ) My agent is not authorized to consent to the administration of electroconvulsive therapy.
( ) My agent is authorized to consent to my participation in experimental studies if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believes that the potential benefits to me outweigh the possible risks to me.
( ) My agent is not authorized to consent to my participation in experimental studies.
( ) My agent is authorized to consent to my participation in drug trials if, after consultation with my treating physician and any other individuals my agent deems appropriate, my agent believes that the potential benefits to me outweigh the possible risks to me.
( ) My agent is not authorized to consent to my participation in drug trials.
Examples of other information that may be included:
Activities that help or worsen symptoms.
Type of intervention preferred in the event of a crisis.
Mental and physical health history.
Dietary requirements.
Religious preferences.
Temporary custody of children.
Family notification.
Limitations on release or disclosure of mental health records.
Other matters of importance.
This power of attorney may be revoked in whole or in part at any time, either orally or in writing, as long as I have not been found to be incapable of making mental health decisions.
My revocation will be effective upon communication to my attending physician or other mental health care provider, either by me or a witness to my revocation, of the intent to revoke. If I choose to revoke a particular instruction contained in this power of attorney in the manner specified, I understand that the other instructions contained in this power of attorney will remain effective until:
I understand that this power of attorney will automatically terminate two years from the date of execution unless I am deemed incapable of making mental health care decisions at the time the power of attorney would expire.
I understand that I may nominate a guardian of my person for consideration by the court if incapacity proceedings are commenced pursuant to 20 Pa.C.S. § 5511. I understand that the court will appoint a guardian in accordance with my most recent nomination except for good cause or disqualification. In the event a court decides to appoint a guardian, I desire the following person to be appointed:
(Insert name, address, telephone number of designated person)
( ) The appointment of a guardian of my person will not give the guardian the power to revoke, suspend or terminate this power of attorney.
( ) Upon appointment of a guardian, I authorize the guardian to revoke, suspend or terminate this power of attorney.
I am making this power of attorney on the (insert day) of (insert month), (insert year).
My signature:
(My name, address, telephone number)
Witnesses' signatures:
(Names, addresses, telephone numbers of witnesses)
If the principal making this power of attorney is unable to sign it, another individual may sign on behalf of and at the direction of the principal.
Signature of person signing on my behalf:
(Name, address telephone number)
20 Pa.C.S. § 5833