(755 ILCS 43/75)
Sec. 75.
Form of declaration.
A declaration for mental health treatment
shall be in substantially the following form:
DECLARATION FOR MENTAL HEALTH TREATMENT
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 for a
period up to 17 days.
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:
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Conditions or limitations:...........................................................................................................
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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.
This directive cannot, by law, provide consent to retain me in a facility for
more than 17 days.
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
..................................................................................................................................................
..................................................................................................................................................
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Conditions or limitations:...........................................................................................................
..................................................................................................................................................
ATTORNEY-IN-FACT
I hereby appoint: NAME .................................. ADDRESS ............................... TELEPHONE # ...........................
to act as my attorney-in-fact to make decisions regarding my mental health
treatment if I become incapable of giving or withholding informed consent for
that treatment.
If the person named above refuses or is unable to act on my behalf, or if I
revoke that person's authority to act as my attorney-in-fact, I authorize the
following person to act as my attorney-in-fact:
NAME ................................ ADDRESS ............................. TELEPHONE # .........................
My attorney-in-fact is authorized to make decisions that are consistent with
the wishes I have expressed in this declaration or, if not expressed, as are
otherwise known to my attorney-in-fact. If my wishes are not
expressed and
are not otherwise known by my attorney-in-fact, my attorney-in-fact is to act
in what he or she believes to be my best interest.
.................................
(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:........................... ...........................(Signature of Witness/Date) (Printed Name of Witness)........................... ...........................(Signature of Witness/Date) (Printed Name of Witness)
ACCEPTANCE OF APPOINTMENT AS ATTORNEY-IN-FACT
I accept this appointment and agree to serve as attorney-in-fact to make
decisions about mental health treatment for the principal. I understand that I
have a duty to act consistent with the desires of the principal as expressed in
this appointment. I understand that this document gives me authority to make
decisions about mental health treatment only while the principal is incapable
as determined by a court or 2 physicians. I understand that the principal may
revoke this declaration in whole or in part at any time and in any manner when
the principal is not incapable.
................................... ..........................(Signature of Attorney-in-fact/Date) (Printed Name) ................................... ..........................(Signature of Attorney-in-fact/Date)(Printed Name of Witness)
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
short-term
(up to 17 days) 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 may also appoint a person as your attorney-in-fact to make these
treatment decisions for you if you become incapable. The person you appoint
has a duty to act consistent with your desires as stated in this document or,
if your desires are not stated or otherwise made known to the attorney-in-fact,
to act
in a manner consistent with what the person in good faith believes to be in
your best interest. For the appointment to be effective, the person you
appoint must accept the appointment in writing. The person also has the right
to withdraw from acting as your attorney-in-fact at any time.
This document will
continue in effect for a period of 3 years unless you become incapable of
participating in mental health treatment decisions. If this occurs, the
directive will continue in effect until you are no longer incapable.
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
..................................................................................................................................................
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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 .............. ........................
(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. This declaration will not be valid unless
it is signed by 2 qualified
witnesses who are personally known to you and who are present when you sign or
acknowledge your signature.
(Source: P.A. 89-439, eff. 6-1-96; 90-655, eff. 7-30-98.)
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