Oregon Revised Statutes Chapter 127 § 127.736 — Form

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. I want this declaration to be followed if a court or two capacity evaluators determine that I am unable to make decisions for myself because 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 treatment of mental illness with psychoactive medication, admission to and retention in a health care facility for a given period, convulsive treatment and outpatient services that are specified in this declaration. “Health care facility” could include an inpatient setting, a residential facility, an adult foster home or a hospice program. “Capacity evaluator” means a licensed independent practitioner or a licensed psychologist. ______________________________________________________________________________ CHOICE OF DECISION MAKER If I become incapable of giving or withholding informed consent for mental health treatment, I want these decisions to be made by: (INITIAL ONLY ONE) __  My appointed representative consistent with my desires, or, if my desires are unknown by my representative, in what my representative believes to be my best interests. __  By the mental health treatment provider who requires my consent in order to treat me, but only as specifically authorized in this declaration. APPOINTED REPRESENTATIVE If I have chosen to appoint a representative to make mental health treatment decisions for me when I am incapable, I am naming that person here. I may also name an alternate representative to serve. Each person I appoint must accept my appointment in order to serve. I understand that I am not required to appoint a representative in order to complete this declaration. I hereby appoint: NAME _________ ADDRESS _________ TELEPHONE # _________ to act as my representative to make decisions regarding my mental health treatment if I become incapable of giving or withholding informed consent for that treatment. (OPTIONAL) 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 representative, I authorize the following person to act as my representative: NAME _________ ADDRESS _________ TELEPHONE # _________ My representative 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 representative. If my desires are not expressed and are not otherwise known by my representative, my representative is to act in what he or she believes to be my best interests. My representative is also authorized to receive information regarding proposed mental health treatment and to receive, review and consent to disclosure of medical records relating to that treatment. ______________________________________________________________________________ DIRECTIONS FOR MENTAL HEALTH TREATMENT This declaration permits me to state my wishes regarding mental health treatments including psychoactive medications, admission to and retention in a health care facility for mental health treatment for a period not to exceed the number of days specified below, convulsive treatment and outpatient services. If I become incapable of giving or withholding informed consent to be admitted for inpatient mental health treatment, I CONSENT TO BE ADMITTED TO THE FOLLOWING HEALTH CARE FACILITIES: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If I become incapable of giving or withholding informed consent to be admitted to a health care facility for mental health treatment, and am admitted to a facility listed above, I consent to be admitted when medically necessary for up to: (INITIAL ONLY ONE) _________ 14 days. _________ 30 days. _________ 60 days. _________ ___ days. If I become incapable of giving or withholding informed consent for mental health treatment, I CONSENT TO THE FOLLOWING MENTAL HEALTH TREATMENTS: (May include types and dosage of medications, short-term inpatient treatment, a preferred provider or facility, transp