Mental Health Advance Directive

Personal Information

Name Date of Birth Address Phone Number Email

Statement of Intent

Statement

Treatment Preferences

Preferred Medications Medications NOT to be Administered Preferred Treatment Methods Other Treatments to Avoid

Hospital and Provider Preferences

Preferred Hospitals/Providers Hospitals/Providers to Avoid

Emergency Contacts

Primary Contact Name Primary Contact Phone Secondary Contact Name Secondary Contact Phone

Healthcare Agent (if any)

Agent Name Agent Phone Agent Address

Additional Instructions

Signature

Signature Date