Can I sign electronically?

Yes in most states if the electronic execution meets intent, consent, attribution, and retention requirements under the ESIGN Act (15 U.S.C. ch. 96) and state law; verify any state exceptions before relying on e-signatures.

Are witnesses always required?

Witness requirements vary by state; some states allow notarization instead of witnesses. Confirm your state’s rules to ensure enforceability and avoid drafting errors.

Does an agent need legal training?

No formal training is required, but the appointed agent should understand your wishes and medical decision principles; consider providing written guidance to the agent.

How do I change my directive?

Execute a new Advance Directive and distribute it to providers and your agent. Clearly mark the prior directive as revoked and follow state rules for revocation where applicable.

What if the form is unsigned?

An unsigned directive is typically not enforceable. If execution requirements were not met, providers may rely on other documented statements or seek court guidance.

Where should I store copies?

Keep originals with your legal documents, file a copy in the medical record, provide one to your agent, and retain electronic backups in secure storage compliant with HIPAA if applicable.

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Advance Directive Form

Advance Directive Form

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Mental Health Advance Directive

NOTICE TO PERSONS CREATING A MENTAL HEALTH ADVANCE DIRECTIVE

This is an important legal document. It creates an advance directive for mental health treatment. Before signing this document you should know these important facts:

(1) This document is called an advance directive and allows you to make decisions in advance about your mental health treatment, including medications, short-term admission to inpatient treatment and electroconvulsive therapy.

YOU DO NOT HAVE TO FILL OUT OR SIGN THIS FORM.
IF YOU DO NOT SIGN THIS FORM, IT WILL NOT TAKE EFFECT.

(2) You have the right to appoint a person as your agent to make treatment decisions for you.

(3) The instructions you include with this advance directive and the authority you give your agent to act will only become effective under the conditions you select in this document.

(4) You have the right to revoke this document in writing at any time you have capacity.

(5) This directive will stay in effect until you revoke it unless you specify an expiration date.

(6) You cannot use your advance directive to consent to civil commitment.

(7) If there is anything in this directive that you do not understand, you should ask a lawyer to explain it to you.

(8) You should be aware that there are some circumstances where your provider may not have to follow your directive.

(9) You should discuss any treatment decisions in your directive with your provider.

(10) You may ask the court to rule on the validity of your directive.

PART I.

STATEMENT OF INTENT TO CREATE A
MENTAL HEALTH ADVANCE DIRECTIVE

I, , being a person with capacity, willfully and voluntarily execute this mental health advance directive so that my choices regarding my mental health care will be carried out in circumstances when I am unable to express my instructions and preferences regarding my mental health care.

PART II.

WHEN THIS DIRECTIVE IS EFFECTIVE

YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.

I intend that this directive become effective (YOU MUST CHOOSE ONLY ONE):

Immediately upon my signing of this directive.

If I become incapacitated.

When the following circumstances, symptoms, or behaviors occur:

PART III.

DURATION OF THIS DIRECTIVE YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.

I want this directive to (YOU MUST CHOOSE ONLY ONE):

Remain valid and in effect for an indefinite period of time.

Automatically expire years from the date it was created.

PART IV.

WHEN I MAY REVOKE THIS DIRECTIVE YOU MUST COMPLETE THIS PART FOR THIS DIRECTIVE TO BE VALID.

I intend that I be able to revoke this directive (YOU MUST CHOOSE ONLY ONE):

Only when I have capacity.

Even if I am incapacitated.

PART V.

PREFERENCES AND INSTRUCTIONS ABOUT TREATMENT, FACILITIES, AND PHYSICIANS OR PSYCHIATRIC ADVANCED REGISTERED NURSE PRACTITIONERS

A. Preferences and Instructions About Physician(s) or Psychiatric Advanced Registered Nurse Practitioner(s) to be Involved in My Treatment

I would like the physician(s) or psychiatric advanced registered nurse practitioner(s) named below to be involved in my treatment decisions:

Dr. or PARNP

Contact information:

Dr. or PARNP

I do not wish to be treated by Dr. or PARNP

B. 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

C. Preferences and Instructions About Medications for Psychiatric Treatment (initial and complete all that apply)

I consent, and authorize my agent (if appointed) to consent, to the following medications:

I do not consent, and I do not authorize my agent (if appointed) 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 medication the hospital doctor or psychiatric advanced registered nurse practitioner recommends

I am willing to try any other medications my outpatient doctor or psychiatric advanced registered nurse practitioner recommends

I do not want to try any other medications.

Medication Allergies

I have allergies to, or severe side effects from, the following:

Other Medication Preferences or Instructions

I have the following other preferences or instructions about medications:

D. 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 hospitalizations.

I would also like the interventions below to be tried before hospitalization is considered:

"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

Authority to Consent to Inpatient Treatment

I consent, and authorize my agent (if appointed) to consent, to voluntary admission to inpatient mental health treatment for days (not to exceed 14 days)

If deemed appropriate by my agent (if appointed) and treating physician or psychiatric advanced registered nurse practitioner:

or

Under the following circumstances (specify symptoms, behaviors, or circumstances that indicate the need for hospitalization)

I do not consent, or authorize my agent (if appointed) to consent, to inpatient treatment

Hospital Preferences and Instructions

If hospitalization is required, I prefer the following hospitals:

I do not consent to be admitted to the following hospitals:

E. Preferences and Instructions About Preemergency

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

F. Preferences and Instructions About Seclusion, Restraint, and Emergency Medications

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:

Seclusion

Seclusion and physical restraint (combined)

Medication by injection

Medication in pill or liquid form

G. Preferences and Instructions About Electroconvulsive Therapy (ECT or Shock Therapy)

My wishes regarding electroconvulsive therapy are (sign one):

I do not consent, nor authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy

I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy

I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy, but only under the following conditions:

H. 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:

I. 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 or psychiatric advanced registered nurse practitioner:

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:

J. Refusal of Treatment

I do not consent to any mental health treatment.

PART VI.

DURABLE POWER OF ATTORNEY (APPOINTMENT OF MY AGENT)

(Fill out this part only if you wish to appoint an agent or nominate a guardian.)

A. Designation of an Agent

I appoint the following person as my agent to make mental health treatment decisions for me as authorized in this document and request that this person be notified immediately when this directive becomes effective:

Name:

Address:

Work telephone:

Home telephone:

Relationship:

B. Designation of Alternate Agent

If the person named above is unavailable, unable, or refuses to serve as my agent, or I revoke that person's authority to serve as my agent, I hereby appoint the following person as my alternate agent:

Name:

Address:

Work telephone:

Home telephone:

Relationship:

If my spouse is my agent, that person shall remain my agent even if we become legally separated or our marriage is dissolved, unless there is a court order to the contrary or I have remarried.

D. Limitations on My Agent's Authority

I do not grant my agent the authority to consent on my behalf to the following:

E. Limitations on My Ability to Revoke this Durable Power of Attorney

I choose to limit my ability to revoke this durable power of attorney as follows:

F. Preference as to Court-Appointed Guardian

In the event a court appoints a guardian who will make decisions regarding my mental health treatment, I nominate the following person as my guardian:

Name:

Address:

Work telephone:

Home telephone:

Relationship:

PART VII.

OTHER DOCUMENTS

(Initial all that apply)

Health care power of attorney (chapter 11.94 RCW)

"Living will" (Health care directive; chapter 70.122 RCW)

I have appointed more than one agent. I understand that the most recently appointed agent controls except as stated below:

PART VIII.

NOTIFICATION OF OTHERS AND CARE OF PERSONAL AFFAIRS

(Fill out this part only if you wish to provide nontreatment instructions.)

A. Who Should Be Notified

Name: Address:

Day telephone: Evening telephone:

Name: Address:

Day telephone: Evening telephone:

B. Preferences or Instructions About Personal Affairs

C. Additional Preferences and Instructions:

PART IX.

SIGNATURE

By signing here, I indicate that I understand the purpose and effect of this document and that I am giving my informed consent to the treatments and/or admission to which I have consented or authorized my agent to consent in this directive.

Signature:

Date:

Printed Name:

Witness 1:

Signature:

Date:

Printed Name:

Telephone:

Address:

Witness 2:

Signature:

Date:

Printed Name:

Telephone:

Address:

PART X.

RECORD OF DIRECTIVE

I have given a copy of this directive to the following persons:

PART XI.

REVOCATION OF THIS DIRECTIVE

(Initial any that apply)

I am revoking the following part(s) of this directive (specify):

I am revoking all of this directive.

By signing here, I indicate that I understand the purpose and effect of my revocation and that no person is bound by any revoked provision(s).

Signature:

Date:

Printed Name:

What the Advance Directive Form Is and when it applies

An Advance Directive Form is a written legal document that records a person's preferences for medical care and appoints an agent to make health decisions if the person becomes incapacitated. Typical components include a living will (treatment preferences) and a durable power of attorney for health care (healthcare proxy). The form documents choices about life-sustaining treatment, resuscitation, artificial nutrition and hydration, and organ donation when applicable. States provide standard templates; healthcare providers often request copies for medical records and care planning.

Why an Advance Directive Form matters for patients and caregivers

An Advance Directive clarifies treatment preferences, reduces family uncertainty, and provides legal authority for a named health agent. Properly executed forms help clinicians follow patient wishes and can avoid court-appointed guardianship in incapacity scenarios.

Who typically completes an Advance Directive Form

Adults of any age can complete an Advance Directive; it is especially important for those with chronic illness, progressive conditions, or upcoming major medical procedures.

Patients with chronic or terminal conditions who want written instructions for future care decisions.
Adults planning for incapacity who wish to designate a trusted agent for medical decisions.
Caregivers and family members who need clear guidance to honor the patient’s preferences.

Keep copies with your medical record, give a copy to your appointed agent, and review the form after major life changes.

Core sections found in a professional Advance Directive Form

A complete Advance Directive Form is structured to capture identity, treatment preferences, agent authority, and execution details so it can be relied on by clinicians and institutions.

Identification

Full legal name, date of birth, and address to tie the directive to medical records and avoid confusion with similarly named patients.

Treatment Preferences

Clear instructions on life-sustaining treatments, Do Not Resuscitate (DNR) choices, mechanical ventilation, and artificial nutrition and hydration where desired or refused.

Health Care Agent

Name and contact information of the person authorized to make health decisions, with alternates and any limits on the agent’s authority.

End-of-Life Wishes

Specific guidance on palliative care, pain management, spiritual preferences, and comfort measures to inform clinicians and caregivers.

Organ Donation

Optional section indicating consent for organ and tissue donation, any limitations, and where donor registry information is recorded.

Execution Details

Signature, dated execution, witness attestations, and notary acknowledgement if required by state law to verify validity.

Step-by-step: completing and activating an Advance Directive Form

Follow these practical steps to create a directive that healthcare providers and legal agents can rely on when needed.

01

Gather information: Collect IDs, medical history, and agent contact details.
02

Decide preferences: Choose specific treatments to accept or refuse.
03

Sign with witnesses: Execute the form with required witnesses or notary.
04

Distribute copies: Provide copies to your agent and healthcare providers.

Configure an online Advance Directive workflow

Set up an online signing workflow to collect signatures, witness attestations, and store the executed document in the patient record.

Form Field \| Online Configuration Settings	Configuration
Signature Authentication	Require email plus SMS code for signer identity verification.
Witness Fields	Add witness name, signature, and date fields; mark as required.
Date Stamping	Enable UTC timestamping for legal traceability and audit logs.
Storage Destination	Save final PDF to patient record system or secure cloud storage.

Where to send or record the executed Advance Directive

After execution, route the directive to key custodians to ensure it is available when clinical decisions are needed.

Primary Care Provider: Place a copy in the patient’s active medical record.
Named Health Agent: Provide a signed copy to the designated agent and alternates.
Family or Caregiver: Share copies with immediate family and current caregivers.
Legal Custody: Retain an original or notarized copy with your legal records.

Digital signing and technical requirements to e-submit a directive

Use a secure e-signature workflow that supports witness and notary steps, strong authentication, and audit trails for legal enforceability.

File Formats: PDF or DOCX preferred for preservation.
Authentication: Email + SMS or KBA for higher assurance.
Integrations: Connect to EHRs, Google Drive, or Box for storage.

Ensure the chosen platform supports evidence of intent, signer attribution, and secure retention consistent with ESIGN, UETA, and any applicable HIPAA protections.

Timing: when to sign, review, and present the form

There are no universal filing deadlines for Advance Directives, but timing and review cadence affect usefulness and legal clarity.

When to sign:

Sign when you are competent and can communicate intent; do not delay.

Periodic review:

Review every 3–5 years or after major health, relationship, or residency changes.

Before procedures:

Provide an updated copy before major surgeries or high-risk treatments.

On relocation:

Update if you move to another state with different statute requirements.

When agent changes:

Execute a new directive immediately if you replace your health care agent.

Common preparation mistakes to avoid

Using vague language about treatment preferences that leaves clinicians uncertain about intent.
Failing to have required witnesses or notary at the time of signing, which can void the directive in some states.
Not distributing copies to the appointed agent and healthcare providers, leaving key parties unaware of the directive.
Neglecting to update the form after major life events, creating conflicts between old directions and current wishes.

Potential legal consequences of an incorrect or incomplete directive

Invalid Execution: May render document unenforceable.

Agent Disputes: Leads to family conflict and possible court intervention.

Medical Delay: Clinicians may delay treatment pending clarification.

Guardianship Risk: Court-appointed guardian may override preferences.

Record Mismatch: Conflicting records can frustrate care teams.

HIPAA Exposure: Improper sharing risks protected health information.

Real-world examples of Advance Directive workflows in practice

Practical examples show how organizations and individuals use electronic workflows to collect and preserve directives.

Fertility Centers Example

A healthcare clinic standardized directives collection across locations to ensure patient wishes were captured consistently.

Clinic used secure electronic signatures and stored copies in the EHR.
The centralized process reduced paperwork, ensured availability at the point of care, and allowed staff to verify signed directives quickly when treatment decisions were required.

Mobile Practice Example

A small medical practice collected directives during in-home visits using mobile devices and secure authentication.

Staff captured signatures and witness attestations onsite via a compliant e-signature workflow.
This approach preserved patient intent, reduced follow-up calls, and ensured directives were included in the provider’s electronic record before urgent care situations arose.

Practical tips for accurate and efficient completion

Follow these best practices to ensure an Advance Directive is clear, enforceable, and accessible when needed.

Use precise language

Avoid vague phrases. Specify conditions and treatments clearly so clinicians and agents can interpret your wishes without ambiguity when time is limited.

Confirm witness eligibility

Ensure witnesses are nonbeneficiaries and meet state residency or capacity requirements; record their full details and signatures on the form.

Distribute authoritative copies

Give signed copies to your agent, primary care provider, and the medical records department; carry a wallet card noting that an Advance Directive exists.

Review periodically

Revisit the directive after major events—diagnosis changes, marriage, divorce, or relocation—to confirm it still reflects current preferences.

Frequently asked questions about the Advance Directive Form

Answers to common questions about validity, electronic signing, witnesses, and updating directives to reduce confusion and delay.

Need help? Contact support

Can I sign electronically?
Yes in most states if the electronic execution meets intent, consent, attribution, and retention requirements under the ESIGN Act (15 U.S.C. ch. 96) and state law; verify any state exceptions before relying on e-signatures.
Are witnesses always required?
Witness requirements vary by state; some states allow notarization instead of witnesses. Confirm your state’s rules to ensure enforceability and avoid drafting errors.
Does an agent need legal training?
No formal training is required, but the appointed agent should understand your wishes and medical decision principles; consider providing written guidance to the agent.
How do I change my directive?
Execute a new Advance Directive and distribute it to providers and your agent. Clearly mark the prior directive as revoked and follow state rules for revocation where applicable.
What if the form is unsigned?
An unsigned directive is typically not enforceable. If execution requirements were not met, providers may rely on other documented statements or seek court guidance.
Where should I store copies?
Keep originals with your legal documents, file a copy in the medical record, provide one to your agent, and retain electronic backups in secure storage compliant with HIPAA if applicable.

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