Fill and Sign the Supported Decision Making Agreement 2019docx Form

SUPPORTED DECISION-MAKING AGREEMENT This agreement is governed by the Supported Decision-Making Act, Chapter 1357 of the Texas Estates Code. This supported decision-making agreement is to support and accommodate an individual with a disability to make life decisions, including decisions related to where and with whom the individual wants to live, the services, supports, and medical care the individual wants to receive, and where the individual wants to work, without impeding the self-determination of the individual with a disability. This agreement may be revoked by the individual with a disability or his or her supporter at any time. If either the individual with a disability or his or her supporter has any questions about the agreement, he or she should speak with a lawyer before signing this supported decision-making agreement. Important Information For Supporter: Duties When you agree to provide support to an adult with a disability under this supported decision-making agreement, you have a duty to: 1. act in good faith; 2. act within the authority granted in this agreement; 3. act loyally and without self-interest; and avoid conflicts of interest Appointment of Supporter I, (name of person with disability) ______________________________________, make this agreement of my own free will. I agree and designate that: Name (Name of Supporter): _______________________________________________________ Address: ______________________________________________________________________ Phone Number: ________________________________________________________________ E-mail Address: ________________________________________________________________ is my supporter. My supporter may help me with making everyday life decisions relating to the following: Yes ___ No___ obtaining food, clothing, and shelter Yes ___ No___ taking care of my physical health Yes ___ No___ managing my financial affairs. My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may: 1. Help me access, collect, or obtain information that is relevant to a decision, including medical, psychological, financial, education, or treatment records; 2. Help me understand my options so I can make an informed decision; or 3. Help me communicate my decision to appropriate persons. Yes____ No____ A release allowing my supporter to see protected health information under the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191) is attached. Yes____ No____ A release allowing my supporter to see education records under the Family Education Rights and Privacy Act of 1974 (20 U.S.C. Section 1232g) is attached. Effective Date of Supported Decision-Making Agreement This supported decision-making agreement is effective immediately and will continue until (insert date) _________________________ or until the agreement is terminated by my supporter or me by operation of law. Authorizing and Witnessing of Supported Decision-Making Agreement A supported decision-making agreement must be signed voluntarily, without coercion or undue influence, by the adult with a disability and the supporter in the presence of two or more witnesses OR a notary public. Consent/Signature of Adult with Disability Signed this ________ (day) of ________________ (month), ________ (year) ____________________________________ Signature of Adult with Disability ____________________________________ Printed Name of Adult with Disability Consent/Signature of Supporter I, (name of supporter) _______________________________, consent to act as a supporter under this agreement. __________________________________ Signature of Supporter ____________________________________ Printed Name of Supporter Signature of Witnesses __________________________________ Witness 1 Signature ____________________________________ Printed Name of Witness 1 __________________________________ Witness 2 Signature ____________________________________ Printed Name of Witness 2 Notary Public State of ____________________ County of ___________________ This document was acknowledged before me on _______________________________ (date) by (name of adult with disability) _________________________________ and (name of supporter) ____________________________________________. __________________________________ Signature of Notary ____________________________________ Printed Name of Notary (Seal, if any, of notary) WARNING: PROTECTION FOR THE ADULT WITH A DISABILITY IF A PERSON WHO RECEIVES A COPY OF THIS AGREEMENT OR IS AWARE OF THE EXISTENCE OF THIS AGREEMENT HAS CAUSE TO BELIEVE THAT THE ADULT WITH A DISABILITY IS BEING ABUSED, NEGLECTED, OR EXPLOITED BY THE SUPPORTER, THE PERSON SHALL REPORT THE ALLEGED ABUSE, NEGLECT, OR EXPLOITATION TO THE DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES BY CALLING THE ABUSE HOTLINE AT 1-800-252-5400 OR ONLINE AT WWW.TXABUSEHOTLINE.ORG. DUTY OF CERTAIN PERSONS WITH RESPECT TO AGREEMENT A person who receives the original or a copy of a supported decision-making agreement shall rely on the agreement. A person is not subject to criminal or civil liability and has not engaged in professional misconduct for an act or omission if the act or omission is done in good faith and in reliance on a supported decision-making agreement.