Psychiatric Power of Attorney
Purpose: In emergencies where immediate psychiatric intervention is necessary, having a Psychiatric Power of Attorney in place can expedite decision-making and ensure appropriate care is provided.
I. Appointment of Attorney-In-Fact
I, [Your Name], hereby appoint [Attorney-In-Fact's Name], residing at [Attorney-In-Fact's Address] as my attorney-in-fact ("Agent") to make any decisions for me regarding my psychiatric health care.
II. Powers of the Attorney-In-Fact
My Agent shall have the power and authority to make decisions about my psychiatric care in emergencies where immediate psychiatric intervention is necessary, to the extent permissible under the laws of [State] and the county of [County].
III. Roles and Responsibilities Transferred to Agent
a. Authorization for Emergency Treatment: The Agent shall have the authority to consent to psychiatric treatment on behalf of the Principal in emergencies where immediate intervention is necessary to safeguard the Principal's well-being and prevent harm.
b. Selection of Treatment Providers: The Agent is empowered to select and authorize psychiatric healthcare providers and facilities deemed suitable for the Principal's treatment, considering factors such as reputation, specialization, and proximity to the Principal's location.
c. Access to Medical Records: The Agent shall have the right to access and review the Principal's psychiatric medical records, including treatment history, diagnoses, medications, and any other relevant information necessary for making informed decisions regarding the Principal's psychiatric care.
d. Communication with Healthcare Providers: The Agent is authorized to communicate with psychiatrists, therapists, counselors, and other healthcare professionals involved in the Principal's treatment to gather information, provide consent for treatment, and make decisions consistent with the Principal's best interests.
e. Decision-Making Authority: In non-emergency situations where psychiatric treatment options are to be considered, the Agent shall consult with the Principal's healthcare providers, family members, and other relevant parties to make decisions regarding the course of treatment, including medication management, therapy modalities, and psychiatric hospitalization if deemed necessary.
IV. Term
This Power of Attorney (POA) shall become effective immediately upon the execution and shall remain in effect until revoked by me or upon my death.
V. Revocation
I reserve the right to revoke this Power of Attorney (POA) at any time by providing a written notice of revocation to the Agent.
VI. Severability and Survival
If any part of this Power of Attorney (POA) is declared invalid or unenforceable, such declaration shall not affect the validity or enforceability of the remaining parts.
VII. Governing Law
This Power of Attorney (POA) shall be governed by and construed by the laws of [State] state and the county of [County]
Principal:
[Your Name]
Agent:
[Attorney-In-Fact's Name]
Witness Acknowledgement
We, the undersigned witnesses, attest that the Principal signed this Psychiatric Power of Attorney in our presence and that the Principal appeared to be of sound mind and under no duress or undue influence.
Witness 1:
[Witness 1 full name]
[Date]
Witness 2:
[Witness 2 full name]
[Date]
Notary Acknowledgement
State of [State], County of [County],
On this day of in the year , before me, a Notary Public in and for said County and State, personally appeared [Your Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.
Witness my hand and official seal.
[Notary Public's Name]
My Commission Expires:
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