Mental Health Care Power of Attorney
Principal Information
Full Name
Address
Date of Birth
Agent (Attorney-in-Fact) Information
Full Name
Address
Phone Number
Alternate Agent (Optional)
Full Name
Address
Phone Number
Grant of Authority
Powers Granted to Agent
Special Instructions
Special Instructions
Effective Date
This document will become effective on
Signature
Principal's Signature
Date
Witnesses
Witness 1 Name
Witness 1 Signature
Witness 2 Name
Witness 2 Signature
Notary
Notary Name
Notary Signature
Date