This Form “Declaration for Mental Health Treatment” was developed pursuant to Oregon Revised Statutes (ORS) 127.700 through 127.736.
Use the PDF if you want to print out the document and fill it in by hand.
Use the Word document if you want to fill it in on your computer.
Notice To Person Making a Declaration For Mental Health Treatment
This is an important legal document. It creates a declaration for mental health treatment. Before signing this document, you should know these important facts:
This document allows you to make decisions in advance about certain types of mental health treatment, including psychoactive medication, short-term (not to exceed 17 days) admission to a treatment facility, convulsive treatment and outpatient services. Outpatient services are mental health services provided by appointment by state-licensed professionals and state-licensed programs. The instructions that you include in this declaration will be followed only if a court or two physicians believe that you are incapable of making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments. Your instructions may be overridden if you are being held pursuant to civil commitment law.
You may appoint a person as your representative to make treatment decisions for you if you become incapable. The person you appoint has a duty to act consistently with your desires as stated in the document or, if not state, as otherwise known by the representative. If your representative does not know your desires, he or she must make decisions in your best interests. For the appointment to be effective, the person you appoint must accept the appointment in writing. The person also has the right to withdraw from acting as your representative at any time. A “representative” is also referred to as an “attorney-in-fact” in state law but this person does not need to be an attorney at law.
This document will continue in effect for a period of three years unless you become incapable of participating in mental health treatment decisions. If this occurs, the directive will continue in effect until you are no longer incapable.
Your have the right to revoke this document in whole or in part at any time you have not been determined to be incapable. YOU MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED INCAPABLE BY A COURT OR TWO PHYSICIANS. A revocation is effective when it is communicate to your attending physician or other provider.
If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. This declaration will not be valid unless it is signed by two qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature.
In order for your instructions to be followed, you or your representative must give copies of your completed Declaration form to your physician or mental health provider. Your representative should keep a copy, and it is wise to keep a copy for yourself. You or your representative can submit a complaint to the State if you have concerns about non-compliance with Advanced Directives and/or Mental Health Directives. In Oregon, send your complaint to:
Department of Human Services
Addiction and Mental Health Division
Medicaid Policy Unit
MHO QAPI Coordinator
500 Summer Street, NE, E-86
Salem, Oregon 9730
Notice to Physician or Provider
Under Oregon law, a person may use this declaration to provide consent for mental health treatment or to appoint a representative to make mental health treatment decisions when the person is incapable of making those decisions. A person is “incapable” when, in the opinion of a court or two physicians, the person’s ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that the person currently lacks the capacity to make mental health treatment decisions. This document becomes operative when it is delivered to the person’s physician or other provider and remains valid until revoked or expired. Upon being presented with this declaration, a physician or provider must comply with it to the fullest extent possible. If the physician or provider is unwilling to comply with the declaration, the physician or provider may withdraw from providing treatment consistent with professional judgment and must promptly notify the person and the person’s representative and document the notification in the person’s medical record.
A physician or provider who administers or does not administer mental health treatment according to and in good faith reliance upon the validity of this declaration is not subject to criminal prosecution, civil liability or professional disciplinary action resulting from a subsequent finding of the declaration’s invalidity.
If I make a Declaration for Mental Health Treatment, do hospitals have to follow it?
The Declaration doesn’t even come into play, UNLESS a court or two physicians decide you are not capable of making your own decisions. If that hasn’t happened, you can say what you want and what you don’t want — the document isn’t needed.
Okay, but what if I’m not capable.
Then it can be overridden, but ONLY if you’re being held under civil commitment law. Even then, an override would only happen if it’s necessary and in your best interests.
So if I’m ruled “not capable” and they think it’s “necessary” they do what they want? What’s the point of even having a Declaration?
It’s still a good idea! Even in the rare case where it gets overridden, if you have a Declaration, doctors and other staff can see what your wishes are, and even if not legally required to do so, often they’ll do their best to honor your preferences.
Can I make it more likely that my Declaration will be followed?
YES! Here are two important tasks.
One – share your declaration with your doctor, case manager, clinician, nurse, friends, family, neighbors, pretty much anyone who will listen. If people don’t know your declaration they can’t follow it.
Two – when making out the Declaration, leave the doctors some options — ones you’re comfortable with. Just don’t completely close off every door.
Example: Instead of saying “I do not want any psychoactive medications, ever, in any circumstance.”
You might say, “I do not want psychoactive medications. However, in an emergency only, I want the smallest possible dose of ____ for the shortest possible time.”
See the difference? With the second example, in a crisis, the doctor may still be able to follow your wishes. With the first one, even the smallest one-time dose and the doctors are working without any guidance from you.
NOTE: The above is only a suggestion. If you feel strongly about something, say it — that’s what the Declaration is for.
What kinds of decisions can I include?
The Declaration lets you make decisions about the following:
* Psychoactive medications. What psych meds do you want them to offer you? In what situations? Are there other things they should try first, like talking with you, or giving you space, or making you a cup of tea? Are there meds you do NOT want? Why? (Allergic? Religious reasons? Tried ’em before, those don’t help? Tried it, and it made things worse?) What if you’re offered a med you’ve never tried before?
* Convulsive treatment. (Includes, but is not limited to, electroconvulsive therapy or ECT; there are other convulsive therapies, such as magnetic seizure therapy) Do you want treatment that involves you having convulsions?
* Hospitalization of 17 days or less. Are there hospitals you prefer? Hospitals you do NOT want to go to? What would you like staff need to know if you’re admitted? Are there people you want contacted? What kinds of hospital practices have helped in the past, and what do you want to avoid? How can people best communicate with you when you’re in crisis?
* Outpatient treatment
Your doctor’s name, address, phone and FAX
Known allergies (not just to psych meds)
Any chronic health conditions?