Sample Forms — Psychiatric Advance Directives

(These forms may be printed and used by members of the public)

We have received several requests for forms that psychiatrists can provide to patients who would like to have an advance directive. The document here contains three forms. In order, the first is a combined Declaration (advance directive) and mental health Power of Attorney (giving another person the right to make decisions for the patient; the second is a Declaration alone; and the third is a Power of Attorney. The forms are easily differentiated when printed, as the pagination begins anew with each form. The forms were provided by the firm of Wolf Block Schorr & Solis-Cohen. They are, for all intents and purposes, identical to the model forms in the law itself.

Please note the following:

Patients are NOT required to have a psychiatric advance directive (either a Declaration or Power of Attorney).
You are NOT required to provide forms, but you may. (But you are required to ask patients if they have an advance directive.)
The use of these particular forms is not required. Although the Act contains model forms, almost identical to the attachments, other forms may be used. However, the law does require that certain elements be present.
A patient may elect to have an Advance Directive without having a Power of Attorney, or a Power of Attorney without an Advance Directive. Those who wish to have both may use separate forms for each function, or a combined form.
You may sign as a witness to the Declaration or Power of Attorney, but you may not serve as an agent under a Power of Attorney.

View Psychiatric Advance Directive/Act 194 Sample Forms (PDF)

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Sample Forms — Psychiatric Advance Directives