36-3286

36-3286. Sample mental health
care power of attorney

A person may use any writing that meets the requirements of sections 36-3281 and
36-3282 to create a mental health care power of attorney. The following form is offered
as a sample only and does not prevent a person from using other language or another form.

Mental Health Care Power of Attorney

I, ________________, being an adult of sound mind, voluntarily make this
declaration for mental treatment. I want this declaration to be followed if I
am incapable, as defined in section 36-3281, Arizona Revised Statutes. I
designate _________________ as my agent for all matters relating to my mental
health care including, without limitation, full power to give or refuse
consent to all medical care related to my mental health condition. If my agent
is unable or unwilling to serve or continue to serve, I appoint
____________________, as my agent. I want my agent to make decisions for my
mental health care treatment that are consistent with my wishes as expressed
in this document or, if not specifically expressed, as are otherwise known to
my agent.

If my wishes are unknown to my agent, I want my agent to make decisions
regarding my mental health care that are consistent with what my agent in good
faith believes to be in my best interests. My agent is also authorized to
receive information regarding proposed mental health treatment and to receive,
review and consent to disclosure of any medical records relating to that
treatment.

This declaration allows me to state my wishes regarding mental health
care treatment including medications, admission to and retention in a health
care facility for mental health treatment and outpatient services.

(initial one of the following)

_____ This mental health care power of attorney is irrevocable if I am
unable to give informed consent.

_____ This mental health care power of attorney is revocable at all
times.

The following are my wishes regarding my mental health care treatment if
I become incapable, as defined in section 36-3281, Arizona Revised Statutes:

I consent to the following mental health treatments:

____________________________________________________

By initialing here, I consent to giving my agent the power to admit me
to an inpatient or partial psychiatric hospitalization program, please initial
here: ____ (initial if you consent)

I do not consent to the following mental health treatments:

_____________________________________________________

Additional information about my mental health care treatment needs
(consider including mental or physical health history, dietary requirements,
religious concerns, people to notify and any other matters that you feel are
important):

_____________________________________________________

This mental health care power of attorney is made pursuant to title 36,
chapter 32, article 6, Arizona Revised Statutes, and continues in effect for
all who may rely on it except to those I have given notice of its revocation
pursuant to section 36-3285.

_____________________________________

(signature of principal)

Address of agent________________________________________

________________________________________________________

Telephone number of agent_______________________________

Address of backup agent________________________________

________________________________________________________

Telephone number of backup agent_______________________

Affirmation of witnesses:

I affirm that the person signing this mental health care power of
attorney:

1. Is personally known to me.

2. Signed or acknowledged by his or her signature on this declaration
in my presence.

3. Appears to be of sound mind and not under duress, fraud or undue
influence.

4. Is not related to me by blood, marriage or adoption.

5. Is not a person for whom I directly provide care as a professional.

6. Has not appointed me as an agent to make medical decisions on his or
her behalf.

Witnessed by:

__________________________________ (signature and date)

Acceptance of appointment as agent: (optional)

I accept this appointment and agree to serve as agent to make mental
health treatment decisions for the principal. I understand that I must act
consistently with the wishes of the person I represent, as expressed in this
mental health care power of attorney, or if not expressed, as otherwise known
by me. If I do not know the principal's wishes, I have a duty to act in what I
in good faith believe to be that person's best interests. I understand that
this document gives me the authority to make decisions about mental health
treatment only while that person has been determined to be incapable as that
term is defined in section 36-3281, Arizona Revised Statutes.

_____________________________________

(signature of agent)

_____________________________________

(printed name of agent)