Georgia Psychiatric Advance Directive Form with Instructions

INSTRUCTIONS FOR COMPLETING THE GEORGIA PSYCHIATRIC ADVANCE DIRECTIVE

Please use the following instructions to complete the provided form to the best of your ability. All answers should be accurate and detailed. This information will be used by mental health care providers and your mental health care agent (if applicable) to identify an ongoing mental health crisis and to provide treatment during the crisis according to your wishes.

Instructions for PART ONE: PREFERENCES

PART ONE is required. This section allows you to explain how you would like to receive treatment if you are experiencing a mental health crisis and are unable at that time to make informed decisions about your mental health care. All sections of PART ONE should be completed and should include information from prior mental health crises you may have experienced.

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• Fill in your full name (First, Middle, Last) and date of birth (Month/Day/Year).

1. Statement of Intent
This section states that, at the time you are completing this form, you are doing so of your own free will and that you understand the purpose of the form and how it will be used.

• If you agree with the statements in this section, fill in your full name (First, Middle, Last) on the line provided.

2. Information Regarding My Symptoms This section allows you to explain past mental health crises you have experienced and what things have made your symptoms better or worse.

• First Box: Explain the signs that usually indicate when you are beginning to experience a mental health crisis. This information will help mental health care providers understand when you may need a mental health care evaluation.
• Second Box: Explain any factors that may lead you to experience a mental health crisis or that may make your symptoms worse.
• Third Box: Explain any techniques or factors that may help you feel better during a mental health crisis or that may help the experience to stop.
• Fourth Box: Explain what behavior mental health care professionals should look for that signifies your mental health crisis is ending and when you would like to receive another evaluation to determine if you can make informed decisions at that time. (If 2 you are experiencing a mental health crisis and cannot make informed decisions about your mental health care, it is important for health care providers to know what to look for to know when the crisis is ending or when you can make informed decisions again.)

3. Preferred Clinicians This section is where you can list the contact information of any health care professionals currently providing you mental health care. You can also list the health care professionals that you agree may provide care for you in the event of a mental health crisis and health care professionals that you do not want to provide care for you.

• First Box (A through E): List the names and telephone numbers of any doctors, therapists, pharmacists, or any other mental health care professionals you are currently receiving treatment from or have received treatment from in the past.
• Second Box (A through E): List the names of the health care professionals that you will allow to provide treatment to you in the event of a mental health crisis.
• Third Box: List the names of the health care professionals that you will not allow to provide treatment to you in the event of a mental health crisis.

4. Treatment Instructions

Medications

• First Box: List all medications that you are currently using and that you would like to continue using in the event of a mental health crisis.
• Second Box: List any medications that you prefer to use and that you would like to use in the event of a mental health crisis.
• Third Box: List any medications that you prefer not to use and the reason why you cannot use them.
• Fourth Box: List any medications that you are allergic to.
• Preferred Medications: This section allows you to provide information about what other treatment options you agree may be used if your preferred methods are unavailable for any reason.
  • If you agree that your treating physician may choose and administer a different medication to you in the event your preferred medications are unavailable and you have not appointed a mental health care agent or your mental health care 3 agent is unable to make this decision for you, select “YES”.
  • If you do not agree that your treating physician may choose and administer a different medication to you in the event your preferred medications are unavailable and you have not appointed a mental health care agent or your mental health care agent is unable to make this decision for you, select “NO”.
  • There are several different techniques listed that may be used to administer medicine to you. For each technique, if you agree that it may be used in the event you need to receive medicine, initial next to “YES” in the space provided. If you do not agree that the technique may be used, initial next to “NO” in the space provided. If you select “NO”, please explain why you do not consent to receiving medication using that technique.

Hospitalization

This form assumes that hospitalization is not your first choice. You would prefer to stay at home, if possible, rather than be admitted to a hospital or mental health facility in the event of a mental health crisis.

• First Box: List any supports you would prefer to receive to help you stay at home while experiencing a mental health crisis.
• Second Box: Outpatient therapy is treatment that you receive without being admitted to a hospital. If a treating physician determines that you would benefit from outpatient therapy, list a health care provider that you agree may provide this care to you.
• Third Box: Provide any additional information or instructions that may be helpful in avoiding hospitalization.

Treatment Facilities

This section allows you to state which facilities you prefer to be treated at if hospitalization becomes necessary, which facilities you do not consent to being treated at and the reasons why, your general reactions to being admitted to a facility, and ways that facility staff can help you while staying in the facility. You can also list any people that you give permission to visit you while you are staying in the facility. Please list the visitor’s full name, relationship to you, and their contact information.

Additional Interventions

This section allows you to state any additional treatment techniques that may be used in the event you experience a mental health crisis. For each technique, if you agree that the 4 technique may be used, initial in the space next to “YES”. If you do not agree that the technique may be used, initial in the space next to “NO”. Please explain the reason for each answer.

5. Additional Statements

This section does not have to be completed, but you may do so if you prefer. This section allows you to provide additional instructions to treating physicians or your mental health care agent (if applicable) about how you want to receive mental health care in the event of a mental health emergency. This information could relate to your personal or religious beliefs and how those impact your preferences for receiving treatment. This information will be useful to your treating physician or mental health care agent in deciding the best treatment options based on your personal wishes.

• If you wish to provide additional information about your wishes for receiving mental health care treatment, list that information in the box provided. If you do not wish to provide additional information, leave the box blank.

Instructions for PART TWO: MENTAL HEALTH CARE AGENT

Part Two is optional. It allows you to select a mental health care agent who will make mental health care decisions on your behalf if you are unable to do so. This section does not have to be completed, but you may do so if you prefer. If you do not want to appoint an agent, do not complete this section. A provider who is involved with your mental health care or an employee of the provider cannot serve as your mental health care agent unless they are a family member, friend, or associate not directly involved with your health care. An employee of a local mental health agency also cannot serve as your mental health care agent unless they are a family member, friend, or associate not directly involved with your health care.

6. Mental Health Care Agent

• If you wish to select a mental health care agent, provide their contact information, including their name, address, home phone, work phone, and mobile phone in the boxes provided.
• You should talk with your mental health care agent about your preference for them to make health care decisions for you in the event you are unable to do so. If your agent agrees to serve in this role, the agent will write their full name, your full name, and sign and date in the boxes provided.

7. Back-Up Mental Health Care Agent

• If you wish to select another mental health care agent to make health care decisions on your behalf if you are unable to do so, and your first designated agent is also unable to do so, please provide their contact information, including their name, 5 address, home phone, work phone, and mobile phone in the boxes provided.
• You should talk with your back-up mental health care agent about your preference for them to make health care decisions for you in the event you are unable to do so. If your back-up agent agrees to serve in this role, the agent will write their full name, your full name, and sign and date in the boxes provided.

8. General Power This section explains the actions that your mental health care agent may take on your behalf in the event you are unable to make mental health care decisions on your own. If you select a mental health care agent or back-up mental health care agent, please read this section in full with those agents.

9. Guidance For Mental Health Care Agent

• If there are any actions that you do not want your mental health care agent to take on your behalf, explain those in the box provided. Your agent will use these instructions to decide the best treatment options that align most closely with your wishes.

10. When Spouse Is Mental Health Care Agent If you are married and select your spouse to act as your mental health care agent, they will automatically be removed from that role if you ever divorce. However, this section allows you to indicate whether you would still want your spouse to remain your mental health care agent even if you do divorce.

• If you want your spouse to remain your mental health care agent if you divorce, initial in the space provided.
• If you do not want your spouse to remain your mental health care agent if you divorce, leave this section blank.

Instructions for PART THREE: OTHER RELATED ISSUES

Part Three is optional and allows you to provide additional information that may be useful in the event of a mental health emergency. This section does not have to be completed, but you may do so if you prefer.

11. Guidance for Law Enforcement

• First Box: List your general reaction to law enforcement, including any past experiences you have had interacting with law enforcement during a mental health crisis.
• If there are any people who may be useful to contact in the event law enforcement becomes involved during a mental health crisis, list their contact information, including their name, relationship, home phone, work phone, and mobile phone in the boxes provided.

12. Help From Others

• If there are any people who provide support to you and who should be notified if you are experiencing a mental health crisis, please list those people in the boxes provided, including their name, relationship, contact information, and responsibility. For example, these people could be your friends, family, neighbors, or treating physicians.

Instructions for PART FOUR: EFFECTIVENESS AND SIGNATURES

Part Four is required. You and your witnesses sign the form here to make it effective. This section must be completed for the form to be valid. If you do not sign or do not have two proper witnesses sign, the form will not be binding on any treating physicians or mental health care agents.

• First Box: You may choose whether you want the form the take effect upon a specific date. If you do not want to pick a specific date, the form will take effect immediately after you and your witnesses sign. If you want to pick a specific date for the form to take effect, list that date in the box provided. If you do not want to pick a date and want the form to take effect immediately, leave this box blank.
• Second Box: You may also choose whether you want the form to end upon a specific date. If you do not want to pick a specific date, the form will remain in effect until you otherwise terminate it. If you want to pick a specific date for the form to terminate, list that date in the box provided. If you do not want to pick a date and want the form to remain effective, leave this box blank.
• Third Box: If you agree that you are of sound mind at the time of creating this form and that you understand the purpose of the document, sign in the box provided and then provide the date.

Your two witnesses must then complete the final sections of the form by signing and providing their name and address. The witnesses must be of sound mind and at least 18 years of age. The witnesses cannot be a person who was selected as your mental health care agent or back-up mental health care agent in Part Two. The witnesses also cannot be a provider who is involved with your health care or an employee of the provider unless they are a family member, friend, or associate not directly involved with your health care. The witnesses also cannot be an employee of a local mental health agency unless they are a family member, friend, or associate not directly involved with your health care.

After you sign the form and two witnesses sign the form, the form is valid. Keep the original signed document in a safe, easily accessible place in your home. Provide copies to your friends, family, and mental health care agents (if applicable).

Georgia Psychiatric Advance Directive Form  

By: _______________________________ Date of Birth:  _____________________
             (Print Name)                                                                (Month/Day/Year)  

1. STATEMENT OF INTENT  
I,_______________________________________ , being of sound mind, willfully and voluntarily make  this psychiatric advance directive as a means of expressing in advance my informed choices and consent regarding my mental health care in the event I become incapable of making informed decisions on my  own behalf. I understand this document becomes effective if it is determined by a physician or licensed psychologist who has personally examined me, or in the opinion of a court, that I lack the capacity to  understand the risks, benefits, and alternatives to a mental health care treatment decision under  consideration and I am unable to give or communicate rational reasons for my mental health care  treatment decisions because of impaired thinking, impaired ability to receive and evaluate information, or  other cognitive disability.  

If I am deemed incapable of making mental health care decision, I intend for this document to constitute  my advance authorization and consent, based on my past experiences with my illness and knowledge gained from those experiences, for treatment that is medically indicated and consistent with the  preferences I have expressed in this document.  

I understand the document continues in operation only during my incapacity to make mental health care  decisions. I understand I may revoke this document only during periods when I am mentally capable.  

I intend for this psychiatric advance directive to take precedence over any advance director for health  care, durable power of attorney for health care, health care proxy or living will that I have executed prior  to executing this form to the extent that such other documents relate to mental health care and are  inconsistent with this executed document.  

In the event that a decision maker is appointed by the court to make mental health care decisions for me, I  intend this document to take precedence over all other means of determining my intent while I was competent.  

It is my intent that a person or facility involved in my care shall not be civilly liable or criminally  prosecuted for honoring my wishes as expressed in this document or for following the directions of my  agent. 
 
2. INFORMATION REGARDING MY SYMPTOMS  
The following are symptoms or behaviors I typically exhibit when escalating toward a mental health  crisis. If I exhibit any of these symptoms or behaviors, an evaluation may be needed regarding whether I  am capable of making mental health care decisions (Limit 500 characters/no spaces):  

The following may cause me to experience a mental health crisis or to make my symptoms worse (Limit  500 characters/no spaces):  

 

The following techniques may be helpful in de-escalating my crisis (Limit 500 characters/no spaces): 

When I exhibit the following signs, I would like to be evaluated to determine whether I have regained the  capacity to make my mental health care decisions:  

3. PREFERRED CLINICIANS  
The names of my doctors, therapists, pharmacists, and other mental health care professionals and their  telephone numbers are:  
A. 
B  
C  
D  
E.

 
I prefer and consent to treatment from the following clinicians:  
Names:  
A  
B  
C  
D  
E. 

I refuse to be treated by the following clinicians:  

 

4. TREATMENT INSTRUCTIONS  
Medications  

I am currently using and consent to continue to use the following medications (include all medications,  whether for mental health care or general health care treatment).  

If additional medications become necessary, I prefer and consent to take the following medications:  I cannot tolerate the following medications because:  

I am allergic to the following medications: 

If my preferred medications cannot be given and I have not appointed an agent in PART TWO to make  alternative decisions for me, I want my treating physician to choose an alternative medication that would  best meet my mental health needs, subject to any limitations I have expressed in my treating instructions  above. (Check “yes” if you agree with this statement or “no” if you disagree with this statement.)  
 Yes  
 No  

In the event I need to have medications administered, I would prefer and consent to the following methods  (Check “yes” or “no” and list a reason for your request if you have one.):  
Medication in pill form:  
 Yes  
 No  

Reason for no medication in pill form:  

Liquid medication:  
 Yes  
 No  

Reason for no medication in liquid form:  

Medication by injection:  
 Yes  
 No  

Reason for no medication by injection  

Covert medication (without my knowledge in drink or food):  
 Yes  
 No  

Reason for no hidden medication: 

Hospitalization  
Hospitalization is not my first choice. It is my intention, if possible, to stay at home or in the community  with the following supports:  

If I need outpatient therapy, I prefer and consent to it being provided by:  

Additional instructions that may help me avoid a hospitalization:  

Treatment Facilities  
If it becomes necessary for me to be hospitalized, I would prefer and consent to being treated at the  following facilities:  

I refuse to be treated at the following facilities:  

Reason (s) for wishing to avoid the above facilities:  

I generally react to being hospitalized as follows: 

Staff at a facility can help me by doing the following:  

I give permission for the following people to visit me:  
1. Visitor name, relationship, and contact information  

2. Visitor name, relationship, and contact information  

3. Visitor name, relationship, and contact information  

4. Visitor name, relationship, and contact information  

5. Visitor name, relationship, and contact information  

Additional Interventions  
I prefer the following interventions as indicated by my initials, and I consent to any intervention where I  have initialed next to “yes.” (Please place your initials in the blanks.)  

Seclusion:  
 Yes  
 No  

Reason:  

Physical Restraint:  
 Yes  
 No  

Reason:  

Experimental treatment:  
 Yes  
 No  

Reason: 

Electroconvulsive therapy (ECT):  
 Yes  
 No  

Reason: 

Any limitations on consent to the administration of electroconvulsive therapy:  

Other instructions as to my preferred interventions:  
` 
5. ADDITIONAL STATEMENTS  
This section is optional. PART ONE will be effective even if this section is left blank. This section  allows you to state additional mental health treatment preferences, to provide additional guidance to your  mental health care agent (if selected in PART TWO), or to provide information about your personal or  religious values about your mental health care and treatment. Understanding that you cannot foresee  everything that could happen to you, you may want to provide guidance to your mental health care agent  about following your mental health treatment preferences.  
 

PART TWO: MENTAL HEALTH CARE AGENT  

PART ONE will be effective even if PART TWO is not completed. If you do not wish to appoint an  agent, do not complete PART TWO. A provider who is directly involved in your health care or any  employee of that provider may not serve as your mental health care agent unless the employee is your  family member, friend or associate and is not directly involved in your health care. An employee of the  Department of Behavioral Health and Developmental Disabilities or a local public mental health agency  or of any organization that contracts with a local public mental health authority may not serve as your  mental health care agent unless the person is your family member, friend or associate and is not directly  involved in your health care. If you are married, a future divorce or annulment of your marriage will  revoke the selection of your current spouse as your mental health care agent unless you indicate  otherwise. If you are not married, a future marriage will revoke the selection of your mental health care  agent unless the person you selected as your mental health care agent is your new spouse.  

6. MENTAL HEALTH CARE AGENT  
I select the following person as my mental health care agent to make mental health care decisions for me:  
Name:  
Address:  
Home Phone:  
Work Phone:  
Mobile Phone:  

Agent’s acceptance: I have read this form, and I certify that I do not, have not, and will not provide mental health care and treatment for:  Full name: _________________________

I accept the designation as agent for:  Full name:_____________________

Agent’s signature/date:  
 

7. BACK-UP MENTAL HEALTH CARE AGENT  
PART TWO will be effective even if this section is left blank.  
If my mental health care agent cannot be contacted in a reasonable time period and cannot be located with  reasonable efforts or for any reason my mental health care agent is unavailable or unable or unwilling to  act as my mental health care agent, then I select the following, each to act successively in the order named,  as my back-up mental health care agent (s):  
Name:  

Address:  
Home Phone:  
Work Phone:  
Mobile Phone: 

Back-up Agent’s acceptance: I have read this form, and I certify that I do not, have not, and will not provide mental health care and treatment for:  Full name ___________________________

I accept the designation as agent for:  Full name ________________________
Back-up Agent’s signature/date:

8. GENERAL POWER  
My mental health care agent will make mental health care decisions for me when I have been determined  in the opinion of a physician or licensed psychologist who have personally examined me, or in the  opinion of the court, to lack the capacity to understand the risks and benefits of, and the alternatives to,  mental health care treatment decisions under consideration and I am unable to give or communicate  rational reasons for my mental health care decisions because of impaired thinking, impaired ability to  receive and evaluate information, or other cognitive disability.  

My mental health care agent will have the same authority to make any mental health care decision that I  could make. My mental health care agent’s authority includes, for example, the power to:  

• Request and consent to admission or discharge from any facility;  
• Request, consent to, authorize, or withdraw consent to any type of provider or mental health care  that is consistent with my instructions in PART ONE of this form and subject to the limitations  set forth in Section 4 of PART ONE; and  
• Contract for any health care facility or service for me, and to obligate me to pay for these services  (and my mental health care agent will not be financially liable for any services or care contracted  for me or on my behalf).  

My mental health care agent will be my personal representative for all purposes of federal or state law  related to privacy of medical records (including the Health Insurance Portability and Accountability Act  of 1996; HIPAA) and will have the same access to my medical records that I have and can disclose the  contents of my medical records to others for my ongoing mental health care.  

My mental health care agent may accompany me in an ambulance or air ambulance if in the opinion of  the ambulance personnel protocol permits a passenger, and my mental health care agent may visit or  consult with me in person while I am in a facility if its protocol permits visitation.  

My mental health care agent may present a copy of this psychiatric advance directive in lieu of the  original, and the copy will have the same meaning and effect as the original.  

I understand that under Georgia law:  

• My mental health care agent may refuse to act as my mental health care agent; and  
• A court can take away the powers of my mental health care agent if it finds that my mental health  care agent is not acting in accordance with this directive.  

9. GUIDANCE FOR THE MENTAL HEALTH CARE AGENT  
In the event my directive is being used, my agent should first look at my instructions as expressed in  PART ONE. If a situation occurs for which I have not expressed a preference, or in the event my  preference is not available, my mental health care agent should think about what action would be  consistent with past conversations we have had, my treatment preferences as expressed in PART ONE,  my religious and other beliefs and values, and how I have handled medical and other important issues in  the past. If what I would decide is still unclear, then my mental health care agent should make decisions  for me that my mental health care agent believe are in my best interests, considering the benefits,  burdens, and risks of my current circumstances and treatment options.  

I impose the following limitations on my agent’s authority to act on my behalf:  

10. WHEN SPOUSE IS MENTAL HEALTH CARE AGENT (initial if you agree with the  following statement; leave blank if you do not agree)  

I desire the person I have named as my agent, who is now my spouse, to remain  my agent even if we become divorced or our marriage is annulled. 
 

PART THREE: OTHER RELATED ISSUES  

PART THREE is optional. This psychiatric advance directive will be effective even if PART  THREE is left blank.  

11. GUIDANCE FOR LAW ENFORCEMENT  
I typically react to law enforcement in the following ways:  

The following person (s) may be helpful in the event of law enforcement involvement:
Name:  
Relationship:  
Home Phone:  
Work Phone:  
Mobile Phone:  
Name:  
Relationship:  
Home Phone:  
Work Phone:  
Mobile Phone:  

12. HELP FROM OTHERS  
The following people are part of my support system and should be contacted in the event of a crisis:  

1. Supporter name, relationship, contact information, and responsibility  

2. Supporter name, relationship, contact information, and responsibility  

3. Supporter name, relationship, contact information, and responsibility 

PART FOUR: EFFECTIVENESS AND SIGNATURES  

This psychiatric advance directive will become effective only if I have been determined in the opinion of  a physician or licensed psychologist who has personally examined me, or in the opinion of a court, to lack the capacity to understand the risks and benefits of, and the alternatives to, a mental health care decision  under consideration and I am unable to give or communicate rational reasons for my mental health care decisions because of impaired thinking, impaired ability to receive and evaluate information or other  cognitive disability.  

This form revokes any psychiatric advance directive I have executed before this date. To the extent this  form is in conflict or is inconsistent with any advance directive for health care, durable power of attorney  for health care, health care proxy, or living will executed by me at any time, this form shall control with  respect to my mental health care.  

Unless I have initialed below and have provided alternative future dates or events, this psychiatric  advance directive will become effective at the time I sign it and will remain effective until my death.  

______ This psychiatric advance directive will become effective on or upon (date)_______.  

(Initials)  

______ This psychiatric advance directive will terminate on or upon (date) _______.  

(Initials)  

You must sign and date or acknowledge signing and dating this form in the presence of two witnesses.  Both must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be together or present with you when you sign this form.  

A witness:  

• Cannot be a person who was selected to be your mental health care agent or back-up mental  health care agent in PART TWO;  
• Cannot be a provider who is providing mental health care to you at the time you execute this  directive or an employee of the provider unless the witness is your family member, friend, or  associate and is not directly involved in your mental health care; and  
• Cannot be an employee of the Department of Behavioral Health and Developmental Disabilities  or of a local public mental health agency or of any organization that contracts with a local public  mental health authority unless the witness is your family member, friend, or associate and is not  directly involved in your mental health care. 

Signatures  

By signing below, I state that I am of sound mind and capable of making this psychiatric advance  directive and that I understand its purpose and effect.  

____________________________________  _______________________

Signature of Declarant                                      Date  

The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my  personal observation, the declarant appeared to be of sound mind and mentally capable of making this psychiatric advance directive and signed this form willingly and voluntarily.  

____________________________________  _______________________

Signature of First Witness                                 Date  

Print Name:  
Address:  

____________________________________  _______________________

Signature of Second Witness                            Date  

Print Name:  
Address:  

 

This form does not need to be notarized.