Establishing secure connection…Loading editor…Preparing document…

Advance Mental Health Care Directive

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

ADVANCE MENTAL HEALTH CARE DIRECTIVE

Explanation

You have the right to give instructions about your own mental health care. You also have the right to name someone else to make mental health treatment decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding the designation of your health care providers. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

Part 1 of this form is a list of options you may designate as part of your mental health care and treatment. For ease of designating specific instructions, mark those options in Part 1.

Part 2 of this form is a power of attorney for mental health care. This lets you name another individual as your agent to make mental health treatment decisions for you, if you become incapable of making your own decisions, or if you want someone else to make those decisions for you now, even though you are still capable of making your own decisions. You may name alternate agents to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a health care institution where you are receiving care.

You may allow your agent to make all mental health treatment decisions for you. However, if you wish to limit the authority of your agent, you may specify those limitations on the form. If you do not limit the authority of your agent, your agent will have the right to:

(1) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a mental condition;

(2) Select or discharge health care providers and institutions;

(3) Approve or disapprove diagnostic tests, surgical procedures, and programs of medication; and

(4) Approve or disapprove of electroconvulsive treatment.

Part 3 of this form lets you give specific instructions about any aspect of your mental health care and treatment. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of medication and treatment. Space is provided for you to add to the choices you have made or for you to write out any additional wishes.

Part 4 of this form must be completed in order to activate the advance mental health care directive. After completing this form, sign and date the form at the end and have the form witnessed by one or both of the two methods listed below. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any mental health care agents you have named. You should talk to the persons you have named as agents to make sure that they understand your wishes and are willing to take the responsibility.

You have the right to revoke this advance mental health care directive or replace this form at any time, unless otherwise specified in writing in the advance mental health care directive.

If you are in imminent danger of causing bodily harm to yourself or others, or have been involuntarily committed to a health care institution for mental health treatment, the advance mental health care directive will not apply.

PART 1
CHECKLIST OF MENTAL HEALTH CARE OPTIONS

NOTE TO PROVIDER: The following is a checklist of selections I have made regarding my mental health care and treatment. I include this statement to express my strong desire for you to acknowledge and abide by my rights, under state and federal laws, to influence decisions about the care I will receive.
(Declarant: Put a check mark in the left-hand column for each section you have completed.)

PART 2
DURABLE POWER OF ATTORNEY FOR MENTAL HEALTH TREATMENT DECISIONS

(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make mental health care decisions for me:

OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a mental health care decision for me, I designate as my first alternate agent:

OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a mental health care decision for me, I designate as my second alternate agent:

(2) AGENT'S AUTHORITY: My agent is authorized to make all mental health care treatment decisions for me, including decisions to provide, withhold, or withdraw medication and treatment, and all other forms of mental health care, except as I state here:

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my supervising health care provider who is a physician and one other physician or licensed psychologist determine that I am unable to make my own mental health care decisions.

(4) AGENT'S OBLIGATION: My agent shall make mental health care decisions for me in accordance with this power of attorney for mental health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make mental health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(5) NOMINATION OF GUARDIAN: If a guardian needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated.

PART 3
INSTRUCTIONS FOR MENTAL HEALTH CARE AND TREATMENT

If you are satisfied to allow your agent to determine what is best for you, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not want.

(6) My preference of treating facility and alternatives to hospitalization:

(7) My preferences about the physicians or other mental health care providers who will treat me if I am hospitalized:

(8) My preferences regarding medications:

(9) My preferences regarding electroconvulsive therapy (ECT or shock treatment):

(10) My preferences regarding emergency interventions (seclusion, restraint, medications):

(11) Consent for experimental drugs or treatments:

(12) Who should be notified immediately of my admission to a facility:

(13) Who should be prohibited from visiting me:

(14) My preferences for care and temporary custody of my children or pets:

(15) My preferences about revocation of my advance mental health care directive during a period of incapacity:

(16) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:

PART 4
WITNESSES AND SIGNATURES

(17) EFFECT OF COPY: A copy of this form has the same effect as the original.

(18) SIGNATURES: Sign and date the form here:

(19) WITNESSES: This power of attorney will not be valid for making mental health care decisions unless it is either: (a) signed by two qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (b) acknowledged before a notary public in the State.

AFFIRMATION OF WITNESSES

Witness 1

I declare under penalty of false swearing pursuant to section 710-1062, Hawaii Revised Statutes, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as agent by this document, and that I am not a health care provider, nor an employee of a health care provider or facility. I am not related to the principal by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

Witness 2

I declare under penalty of false swearing pursuant to section 710-1062, Hawaii Revised Statutes, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as agent by this document, and that I am not a health care provider, nor an employee of a health care provider or facility. I am not related to the principal by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

DECLARATION OF NOTARY

State of Hawaii
County of

On this day of in the year , before me,
appeared
personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it.

Notary Seal

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What an Advance Mental Health Care Directive Is

The Advance Mental Health Care Directive is a legal document that lets an adult designate specific instructions and a trusted decision-maker for mental health treatment in the event they cannot communicate or make informed decisions. It typically addresses admission preferences, medications, crisis interventions, electroconvulsive therapy, and the selection of an agent to consent to or refuse psychiatric care. The Directive complements general advance directives and durable powers of attorney by focusing on psychiatric care preferences and legally documenting treatment wishes in advance.

Why this Directive Matters for Treatment Clarity

An Advance Mental Health Care Directive clarifies a person's treatment preferences, reduces uncertainty during crises, and provides legal authority for a named health care agent to make psychiatric decisions. It helps clinicians and loved ones follow documented wishes consistent with ESIGN/UETA and applicable state law.

Why this Directive Matters for Treatment Clarity

Who typically completes or relies on this Directive

Typical users include adults with mental health histories, their chosen support persons, and clinicians involved in psychiatric care planning.

  • Adults with psychiatric conditions who want clear treatment directives and to avoid unwanted interventions.
  • Designated agents, family members, or caregivers responsible for decision-making during crises.
  • Behavioral health clinicians, hospital legal teams, and community providers referencing documented preferences.

Core elements included in a professional Directive

A complete Advance Mental Health Care Directive identifies an agent, states treatment preferences, provides crisis instructions, defines the capacity standard, sets duration and review terms, and specifies execution formalities required by law.

Agent designation

Name the person authorized to make psychiatric treatment decisions, include contact details, relationship, and any limits on their authority such as scope, duration, or actions not permitted.

Treatment preferences

Specify accepted and refused interventions (medications, psychotherapy, seclusion, restraint, ECT), any preferred medications or dosages, and situations where treatment consent should be withdrawn to align with personal values.

Crisis instructions

Describe advance instructions for psychiatric emergencies, including preferred admission settings, de-escalation methods, refusal of specific interventions, and contact protocol for crisis teams.

Capacity standard

State the decision-making capacity threshold the clinician should use when determining incapacity and whether a substituted decision-maker should act.

Duration and review

Declare when the Directive takes effect, any expiration or review dates, and procedures for periodic reassessment or automatic termination conditions.

Execution formalities

Include signer signatures, dates, witness and notary blocks as required by state law, and any acknowledgements of consent to electronic records where applicable.

Step-by-step: completing and validating the Directive

Step-by-step process to complete, validate, and distribute your Advance Mental Health Care Directive for enforceability and practical use.

  • 01
    Draft: Identify preferences and choose an agent.
  • 02
    Consult: Review with clinician and legal counsel.
  • 03
    Execute: Sign with required witnesses and notarization.
  • 04
    Distribute: Share copies with agent, providers, and trusted contacts.

Digital workflow settings to collect signatures and evidence

Configure digital workflow elements to collect signatures, authenticate signers, and route completed Directives to designated recipients.

Field Configuration
Signer authentication Email link; SMS OTP available for higher assurance.
Signature fields Signature, initials, date, and agent consent checkbox.
Conditional fields Show treatment specifics only when agent consent checked.
Distribution Auto-send PDF to agent, clinician, and personal contacts.

How electronic completion and routing typically works

High-level routing: digital preparation, signer authentication, remote signing, and secure delivery with audit evidence for each action.

  • Upload: Add the Directive PDF and configure fields.
  • Assign signers: Enter agent and witness contact information.
  • Authenticate: Choose email, SMS OTP, or KBA where required.
  • Complete: System records audit trail and issues final PDF.

Technical and compliance considerations for eSubmission

Basic technical and integration needs for e-submission, secure storage, and strong signer authentication across clinical and legal systems.

  • Formats: PDF and Word DOCX supported.
  • Integrations: Works with EHRs, CRM, cloud storage.
  • Authentication: Email, SMS code, and optional KBA.

Security and compliance features to look for

Encryption in transit: TLS 1.2 and 1.3 for data in transit
Encryption at rest: AES-256 encryption for stored data
Certifications: SOC 2 Type II; ISO 27001; PCI DSS
HIPAA compliance: BAA available for covered entities
21 CFR Part 11: Controls available for FDA-regulated records
Access controls: Role-based access and audit trails

Immediate risks from an incorrectly executed Directive

Invalid Execution: Document may be void without proper witnesses
Treatment delay: Clinicians may defer decisions
Criminal risk: Involuntary admission risks if unclear
Civil liability: Care decisions may prompt disputes
HIPAA breach: Improper sharing can trigger HIPAA penalties
State noncompliance: Failure to meet state formalities invalidates directive

Common mistakes to avoid when preparing the Directive

  • Using vague language (for example, 'no aggressive treatment') that leaves clinicians to interpret intent can result in treatment contrary to the individual's wishes.
  • Failing to name alternates or specify contact information for the agent creates gaps when the primary agent is unavailable during a crisis.
  • Omitting required witness signatures or notarization for your state may render the Directive unenforceable and delay care decisions.
  • Storing only digital copies without verifying access or retention policies can prevent timely retrieval when clinicians need the Directive during emergencies.

Real-world examples of Directive use in clinical settings

Two concise scenarios show how standardized Directives improve crisis response and coordination across care teams.

Case Study 1

A large hospital behavioral health unit used directives to document patient preferences and designate surrogate decision-makers before discharge.

  • Reduced admission conflicts and delays.
  • When directives were standardized and available in the electronic record, clinicians followed documented preferences more consistently, family disputes decreased, and the hospital reported fewer emergency legal consultations related to capacity and consent.

Case Study 2

A community mental health clinic provided signed directives to clients during intake, ensuring care teams had clear crisis plans and designated agents on file.

  • Improved crisis response coordination and clarity.
  • Having directives accessible electronically reduced phone delays when contacting agents, allowed rapid authorization for short-term inpatient care when appropriate, and supported patient-centered decision-making across multidisciplinary teams.

How this Directive differs from a general advance healthcare directive

Side-by-side contrasts clarify scope, activation, and typical use cases between mental health directives and general advance directives.

Criteria Advance Mental Health Care Directive General Advance Directive
Scope psychiatric treatment only broad medical decisions
Activation when impaired capacity when incapacitated
Treatment focus psychiatric interventions medical and surgical interventions
Use case crisis psychiatric care end-of-life and medical care

Representative eSignature vendor pricing and feature snapshot

Basic pricing and feature differences among common eSignature vendors often used for healthcare documents and Directives.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about completing and enforcing this Directive

Answers to frequently asked questions about completing, signing, and enforcing an Advance Mental Health Care Directive across jurisdictions and electronic platforms.


Need help? Contact support

Explore Templates

Missouri Department of Revenue Form 1099 Form 990-T Iowa Individual Income Tax Return Virginia Vending Machine Dealers Sales Tax Return Mississippi Non-Resident or Part-Year Resident Individual Income Tax Return Nebraska County Lodging Tax Return
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.