Mental Health Crisis Advance Directive
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Name
Phone
Relationship
Healthcare Agent / Advocate
Name
Phone
Relationship
Preferred Facilities/Providers
Hospital, Clinic, or Provider
Medications
Current Medications
Medication Allergies
Treatment Preferences
Describe any treatment preferences, including methods that help you during a crisis
What Helps / What Does Not Help
What helps me during a crisis
What does not help/is not effective
Other Instructions
Additional information or instructions
Signature
Date