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Declaration for Mental Health Treatment

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DECLARATION FOR MENTAL HEALTH TREATMENT
(IC 16-36-1.5-7)

I, being an adult of sound mind, willfully and voluntarily make this declaration for mental health treatment to be followed if it is determined by 2 physicians or the court that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment. "Mental health treatment" means electroconvulsive treatment, treatment of mental illness with psychotropic medication, and admission to and retention in a health care facility as provided by law. I understand that I may become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder. These symptoms may include:

PSYCHOTROPIC MEDICATIONS

If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychotropic medications are as follows:

I consent to the administration of the following medications:

I do not consent to the administration of the following medications:

Conditions or limitations:

ELECTROCONVULSIVE TREATMENT

If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding electroconvulsive treatment are as follows:

I consent to the administration of electroconvulsive treatment.

I do not consent to the administration of electroconvulsive treatment.

Conditions or limitations:

ADMISSION TO AND RETENTION IN FACILITY

If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding admission to and retention in a health care facility for mental health treatment are as follows:

I consent to being admitted to a health care facility for mental health treatment.

I do not consent to being admitted to a health care facility for mental health treatment.

Conditions or limitations:

SELECTION OF PHYSICIAN
(OPTIONAL)

If it becomes necessary to determine if I have become incapable of giving or withholding informed consent for mental health treatment, I choose Dr. of to be one of the 2 physicians who will determine whether I am incapable. If that physician is unavailable, that physician's designee shall determine whether I am incapable.

ADDITIONAL REFERENCES OR INSTRUCTIONS

Conditions or limitations:

(Signature of Principal/Date)

AFFIRMATION OF WITNESSES

We affirm that the principal is personally known to us, that the principal signed or acknowledged the principal's signature on this declaration for mental health treatment in our presence, that the principal appears to be of sound mind and not under duress, fraud or undue influence, that neither of us is:

A person appointed as an attorney-in-fact by this document;

The principal's attending physician or mental health service provider or a relative of the physician or provider;

The owner, operator, or relative of an owner or operator of a facility in which the principal is a patient or resident; or

A person related to the principal by blood, marriage or adoption.

Witnessed By:

Witness Signature:

Witness Name:

Address:

Witness Signature:

Witness Name:

Address:

NOTICE TO PERSON MAKING A
DECLARATION FOR MENTAL HEALTH TREATMENT

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

This document allows you to make decisions in advance about 3 types of mental health treatment: psychotropic medication, electroconvulsive therapy, and admission to a treatment facility. The instructions that you include in this declaration will be followed only if 2 physicians or the court believes that you are incapable of making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments. You

have the right to revoke this document in whole or in part at any time you have been determined by a physician to be capable of giving or withholding informed consent for mental health treatment. A revocation is effective when it is communicated to your attending physician in writing and is signed by you and a physician. The revocation may be in a form similar to the following:

REVOCATION

I, willfully and voluntarily revoke my declaration for mental health treatment as indicated

I revoke my entire declaration

I revoke the following portion of my declaration

Date

Signed

(Signature of principal)

I, Dr. have evaluated the principal and determined that he or she is capable of giving or withholding informed consent for mental health treatment.

Date

Signed

(Signature of physician)

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

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What the Declaration for Mental Health Treatment Is

A Declaration for Mental Health Treatment is a legally binding document in which an individual states preferences and directions about psychiatric care, crisis interventions, medications, hospitalization, and the designation of a surrogate decision-maker. It records the individual’s informed choices for future scenarios when they may lack capacity, and can include advance instructions, contact details for appointed representatives, and limits on specific interventions. The form helps clinicians, family members, and authorized agents follow expressed treatment wishes, reduce disputes, and document consent consistent with applicable state and federal rules.

Why a Clear Declaration Matters

A clear declaration preserves patient autonomy, reduces emergency decision-making friction, and documents consent to mental health procedures. It provides clinicians legal clarity and helps avoid contested treatment choices during crises, while supporting continuity of care and compliance with privacy law requirements.

Why a Clear Declaration Matters

Who Typically Prepares and Relies on This Declaration

The form bridges clinical, legal, and family roles; clear completion and distribution reduce confusion during urgent care.

  • Patients and clients preparing advance directives to specify treatment preferences and appoint surrogates during incapacity.
  • Clinicians and treating teams using the declaration to guide emergency care consistent with documented wishes.
  • Legal representatives, guardians, and family members who must interpret or implement treatment instructions.

Core Components Found in a Professional Declaration

A professionally drafted declaration organizes patient directives, surrogate designations, scope of permitted treatments, and execution details. It should be concise, explicit about consent limits, and include authentication fields so clinicians can rely on it in urgent situations.

Patient Identity

Full legal name, date of birth, and identifying information to avoid ambiguity.

Treatment Preferences

Specific choices about medications, electroconvulsive therapy, hospitalization, and conditions under which interventions are allowed.

Surrogate Designation

Name and contact of the person authorized to make decisions if the declarant lacks capacity.

Scope and Limits

Clear statements limiting or permitting certain treatments and any timebound restrictions.

Execution Details

Signature, date, witness or notary block, and any required attestations of capacity.

Emergency Instructions

Concise guidance for first responders or inpatient teams for crisis scenarios.

Required Information and Essential Data Elements

Patient Name: Full legal name as on ID
Date of Birth: MM/DD/YYYY format
Capacity Statement: Declarant affirms current competence
Authorized Agent: Name and contact of surrogate
Treatment Limits: Explicit prohibitions or permissions
Execution Data: Signature, date, witness/notary

Step-by-Step: Completing the Declaration

Follow these sequential steps to complete a clear, enforceable declaration that clinicians and authorized agents can act on without delay.

  • 01
    Gather IDs: Collect government ID and medical record numbers
  • 02
    Define Preferences: Write specific treatment choices and prohibitions
  • 03
    Appoint Surrogate: Name alternate decision-makers with contact info
  • 04
    Execute Properly: Sign with required witness or notary

How to Configure an Online Declaration Workflow

Configure fields and authentication to match clinical and legal needs when building an online version of the declaration.

Field Configuration
Identity Verification Email link with optional SMS code or stronger KBA
Required Fields Make name, DOB, treatment choices mandatory
Witness/Notary Step Insert conditional witness or RON step per state law
Document Retention Automate secure storage and audit log creation

Digital Signing Considerations and Platform Needs

Ensure the platform supports audit trails, HIPAA-compliant handling, and exportable signed copies so clinicians have immediate access.

  • Authentication: Use at least email plus one additional factor for higher assurance
  • Formats: Support PDF and DOCX exports for EMR ingestion
  • Integrations: Connect with EHRs, cloud storage, and secure messaging

Where to Send or File the Signed Declaration

Routing a signed declaration correctly ensures clinicians can retrieve it during emergencies and gives legal notice to appointed agents.

  • Primary Care / Treating Clinician: Upload final signed copy to the patient’s electronic health record
  • Authorized Representative: Provide copy to the appointed surrogate and alternates
  • Emergency Contacts: Share a concise emergency summary with listed contacts
  • Legal Counsel or Recorder: File with attorney or applicable registry if state law requires

Timelines, Review Intervals, and Processing Expectations

Plan regular reviews and note timing triggers so the declaration remains current and clinically actionable.

Effective Date:

Document takes effect on the signed date unless a future date is specified

Periodic Review:

Review every 12 months or after major clinical changes

Emergency Use:

Clinicians should reference the declaration immediately in crises

Update Processing:

Treat updated declarations as superseding prior versions once executed

Retention Trigger:

Follow HIPAA and state retention rules for storage and access

Common Preparation Errors to Avoid

  • Using vague terms like 'no aggressive treatment' that leave clinical actions undefined and lead to misinterpretation.
  • Failing to include full contact details for a surrogate, delaying emergency contact and care decisions.
  • Missing required witness or notary steps that render the declaration invalid under state law.
  • Not sharing the final signed copy with the treating clinician or uploading it to the medical record.

Risks and Legal Consequences of an Incorrect Declaration

Invalid Consent: May result in clinicians refusing to follow directions
HIPAA Breach: Improper sharing of PHI can trigger penalties
Civil Liability: Family disputes may lead to litigation
Treatment Delays: Unclear instructions can postpone necessary care
Insurance Denial: Coverage disputes if consent requirements unmet
Criminal Risk: Fraudulent signatures may bring criminal exposure

Pricing and Feature Snapshot for eSignature Options

Compare common vendor pricing and key capabilities relevant for executing and managing Declarations for Mental Health Treatment; signNow appears first in the comparison.

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 Yes, 7-day trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About Declarations for Mental Health Treatment

Answers to common execution, validity, and practical questions for clinicians, patients, and legal representatives.


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