Healthcare Power of Attorney
Prepared by: [YOUR NAME]
[YOUR EMAIL]
This Healthcare Power of Attorney is designed to ensure that the Principal’s mental health treatment preferences are respected when they are unable to make decisions for themselves. This document appoints a trusted Agent to act on behalf of the Principal in all matters relating to mental health care, from treatment plans to hospitalization decisions, with a focus on protecting the Principal’s well-being and dignity.
I. Appointment of Agent
I, Jerrell Lowe, hereby appoint Jean Harris as my Agent, with full authority to make decisions related to my mental health treatment in accordance with my wishes. The Agent’s power includes, but is not limited to, consent to or refusal of psychiatric treatment, admission to a mental health facility, and management of prescribed medications. Should my Agent be unable or unwilling to serve, I appoint Malcolm Raynor as my alternate Agent.
Agent’s Full Name: Jean Harris
Agent’s Address: Columbus, OH 43215
Agent’s Phone Number: 222 555 7777
Alternate Agent’s Name: Malcolm Raynor
Alternate Agent’s Phone Number: 222 555 7777
II. Mental Health Treatment Preferences
In the event that I become unable to make decisions regarding my mental health care, I instruct my Agent to follow these preferences:
Hospitalization: I consent to psychiatric hospitalization if deemed necessary by my healthcare provider.
Medications: I prefer to take medications that align with my mental health needs, and I authorize my Agent to approve or deny changes in treatment plans as they see fit.
Therapeutic Interventions: My Agent may consent to or refuse specific therapeutic interventions such as psychotherapy, counseling, or alternative treatments.
Electroconvulsive Therapy (ECT): I do not consent to the use of ECT as a treatment option.
Other Treatments: My Agent may consider and authorize any new or experimental treatments that align with my best interests.
III. Execution and Effectiveness
This Healthcare Power of Attorney will take effect only when two licensed physicians certify that I am incapable of making my own mental health treatment decisions. This document shall remain valid until it is revoked in writing by me or superseded by a new Healthcare Power of Attorney.
Date of Execution: August 15, 2052
Location of Execution: New York, NY
IV. Authority and Limitations
My Agent is authorized to:
Approve or deny psychiatric evaluations, consultations, or hospitalization.
Manage my mental health records, ensuring confidentiality and access as needed for decision-making.
Act in accordance with my best interests and express wishes as outlined in this document.
Limitations:
V. Signatures and Witnesses
By signing below, I confirm that I understand the contents of this document, and I willingly appoint my Agent to make mental health treatment decisions on my behalf.
Principal
Date: August 15, 2052
Agent
Date: August 20, 2052
Alternate Agent
Date: August 22, 2052
VI. Witnesses and Notary
This document must be signed in the presence of two witnesses and a notary public. The witnesses attest that the Principal is of sound mind and acting voluntarily when signing this document.
Witness 1 Name: Philip Mitchell
Address: Indianapolis, IN 46201
Phone Number: 222 555 7777
Date: August 15, 2052
Witness 2 Name: Carmel Ryan
Address: Baltimore, MD 21201
Phone Number: 222 555 7777
Date: August 15, 2052
Notary Public
Date: August 22, 2052
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