MENTAL HEALTH ADVANCED DIRECTIVES

1 Instructions and FormsMENTAL HEALTHADVANCED DIRECTIVESFOR PENNSYLVANIANSMENTAL HEALTH ADVANCE DIRECTIVEI, _____,have executed an advance directive specifying mydecisions about my MENTAL HEALTH care. My MENTAL HealthCare Agent is I am hospitalized, my Agent should be immediatelycontacted at _____ - _____ - the hospital has questions about its legalresponsibilities to honor my decisions,it should contactPennsylvania Protection and Advocacyat:1-800-692-7443 Table ofContentsI. 4II. FREQUENTLY ASKED 5 III.

2 COMBINED MENTAL HEALTHDECLARATION/POWER OF 9 InstructionsIV. MENTAL HEALTH 14 InstructionsV. MENTAL HEALTH POWER OF 18 InstructionsVI. GLOSSARY OF 23 VII. 24 Combined (p. 25) Declaration (p. 33) Power of Attorney (p. 39)I. INTRODUCTIONOn November 3, 2004, Governor Rendell signed House Bill 2036 into lawmaking it Act 194 of 2004. By allowing you to create a MENTAL HealthAdvance Directive which can include a Declaration and/or a MentalHealth Power of Attorney this new law promotes planning ahead for themental HEALTH services and supports that you might want to receiveduring a crisis if you are unable to make 194 became effective on January 29, 2005.

3 The passage of thislegislation is largelythe result of collaboration between advocacyorganizations, county governments, professional associations and thestate government. A MENTAL HEALTH Care Advance Directive is a tool thatfocuses on wellness and recovery planning. Pennsylvania is pleased tojoin the national trend of promoting the use of this tool as a mentalhealth is important to understand how to make this new law work for you including how to createan Advance Directive and/or appoint an agent foryour MENTAL HEALTH Power of booklet has been developed to assist you.

4 It includes forms andinstructions that you can use to create your advance directive andanswers to frequently asked questions. If you have additional questionsor need assistance with completing a form, contact any one of thefollowing organizations: Pennsylvania MENTAL HEALTH Consumers' Association 1-800-88 PMHCA Pennsylvania Protection & Advocacy / Disabilities Law Project 1-800-692-7443 717-236-8110 1-877-375-7139 (TDD/TTY) MENTAL HEALTH Association in Pennsylvania 1-866-578-3659 717-346-0549 FREQUENTLY ASKED QUESTIONSWhat is a MENTAL HEALTH Advance Directive?

5 A MENTAL HEALTH Advance Directive is a documentthat allows you to make your choices knownregarding MENTAL HEALTH treatment in the event thatyour MENTAL illness makes you unable to makedecisions. In effect, you are making decisionsabout treatment before the time that you will needit. This allows you to make more informed decisionsand to make your wishes clearly known. Anew law was passed in Pennsylvania, effectiveJanuary 28, 2005, that makes it possible for you touse a MENTAL HEALTH Advance decisions may need to be made for you ifyou have a MENTAL HEALTH crisis or are involuntarilycommitted and become unable to make treatmentdecisions.

6 For example, the choice of hospital,types of treatment, and who should be notified aredecisions that may be made for you. Unfortunately,at the time of crisis, you may not be able to makeyour wishes known, and therefore you may end upwith others making decisions that you would notmake. One way to be sure that your doctor,relatives, and friends understand your feelings is toprepare a MENTAL HEALTH Advance Directive beforeyou become unable to make law allows you to make a MentalHealth Advance Directive that is a declaration, apower of attorney, or a combination of is a Declaration?

7 A Declaration contains instructions to doctors, hos-pitals, and other MENTAL HEALTH care providers aboutyour treatment in the event that you become unableto communicate your wishes. A Declaration usuallydeals with specific situations and does not allowmuch flexibility for changes that come up after thedocument is written, such as a new type of medicalcrisis, new kinds of medication, or differenttreatment is a MENTAL HEALTH Power of Attorney?A MENTAL HEALTH Power of Attorney allows you todesignate someone else, called an agent, to maketreatment decisions for you in the event of a mentalhealth crisis.

8 A MENTAL HEALTH Power of Attorneyprovides flexibility to deal with a situation as itoccurs rather than attempting to anticipate everypossible situation in using a MENTAL HEALTH Power of Attorney it isvery important to choose someone you trust asyour agent and to spend time with that personexplaining your feelings about treatment doctor or his/her employee, or an owner,operator, or employee of a residential facilitywhere you are living cannot serve as an is a Combined MENTAL HEALTH Declaration andPower of Attorney?

9 Pennsylvania's law also allows you to make acombined MENTAL HEALTH Declaration and Power ofAttorney. This lets you make decisions about somethings, but also lets you give an agent power tomake other decisions for you. You choose the deci-sions that you want your agent to make for you, asmany or as few as you like. This makes yourMental HEALTH Advance Directive more flexible indealing with future situations, such as new treat-ment options, that you would have no way ofknowing about agent should be someone you trust, and youshould be sure to discuss with your agent your feel-ings about different treatment choices so that youragent can make decisions that will be most like theones you would have made for makes a MENTAL HEALTH Care AdvanceDirective valid?

10 There is no specific form that must be used, butyour MENTAL HEALTH Advance Directive must meetthe following must be at least 18 years of must not have been declared incapacitat-ed by a court and had a guardian appointed orcurrently be under an MENTAL HEALTH Advance Directive mustbe signed, witnessed and dated. Witnessesmust be at least 18 years old. If you cannotphysically sign the document, another personmay sign for you, but the person signing maynot also be a witness. Your doctor or his/heremployee, or an owner, operator, or employeeof a residential facility where you are livingcannot serve as an MENTAL HEALTH Advance Directive mustcontain your choices about beginning, continuing,or refusing MENTAL HEALTH treatment.