Mental Health Care Preferences

Use this worksheet if you have serious mental health problems and want
to ensure that your health care providers have a clear understanding of
your wishes. Please review this worksheet with them before attaching
this document to your advance directive.\
\
This worksheet is made up of the following parts:

-   [Mental Health Symptoms]{.underline}

-   [Medication and Treatment Preferences for Mental Health]{.underline}

-   [Admission to and Retention in a Mental Health Facility]{.underline}

-   [Other Information and Preferences]{.underline}

MENTAL HEALTH SYMPTOMS

1\. The signs my mental health problems may be getting worse include:

 

**MEDICATION AND TREATMENT PREFERENCES FOR MENTAL HEALTH**

2\. I prefer to receive the following medications, if indicated, because
they were previously helpful when my symptoms were worse:

3\. I do NOT want to receive the following medications \[Identify the
reasons for your preferences, such as bad side effects, concern about
long-term side effects, or the medication not having worked when your
symptoms were worse.\]:

Medication:

Reason:

Medication:

Reason:

Medication:

Reason:

4\. I understand that medications may cause side effects. However, I
would especially like to avoid, if reasonable alternatives exist, the
following bad side effects \[Check up to 4\]:

-   Abnormal movements of your mouth or other areas

-   Loss of sensation (numbness)

-   Motor restlessness (can\'t seem to sit still or stand without
    moving)

-   Seizures (fits or brief periods of twitching or shaking of the body
    that you cannot control and that usually cause you to lose
    consciousness)

-   Muscle/body stiffness (where you can't move your arms, body, or legs
    smoothly or normally)

-   Tremors (for instance, fast shaking or vibrating of your hands that
    you can't control)

-   Nausea (sick to your stomach)/vomiting (throwing up)

-   A dangerous condition involving most or all of the following:
    confusion or coma, severe muscle rigidity, sweating, high fever,
    loss of bladder control, high blood pressure, and trouble swallowing

-   Weight gain / Weight loss

-   Diabetes mellitus (sometimes referred to as the "sugar disease")

-   Problems with sexual functioning

5\. My preferences about [electroconvulsive therapy]{.underline} (or
ECT), which is commonly referred to as \"shock treatment,\" are as
follows:

-   I want to receive ECT if it is thought to be necessary; my
    [surrogate]{.underline} may consent to ECT

-   I do NOT want to receive this even if it is thought to be in my best
    interest.

-   Other:

**ADMISSION TO AND RETENTION IN A MENTAL HEALTH FACILITY**

 

6\. If in need of acute, emergency mental health care because **I am
grossly disabled (unable to take care of myself)**, I prefer an
alternative to hospitalization be considered (e.g., acute follow-up,
mental health case management, prompt follow-up with outpatient mental
health provider).

-   Yes (Specify):

-   No

7\. If in need of acute, emergency mental health care because **I have
active plans to harm another person or persons**, I prefer an
alternative to hospitalization be considered (e.g., acute follow-up,
mental health case management, prompt follow-up with outpatient mental
health provider).

-   Yes (Specify):

-   No

8\. If in need of acute, emergency mental health care because **I have
active plans to take my own life**, I prefer an alternative to
hospitalization be considered (e.g., acute follow-up, mental health case
management, prompt follow-up with outpatient mental health provider).

-   Yes (Specify):

-   No

9\. If I agree beforehand to go to the hospital when I am in a mental
health crisis and out of control, and then say no when professionals
recommend that I go to the hospital, I prefer that this conflict be
handled as follows:

-   Hospitalize me anyway

-   Respect my decision in the moment

-   Defer to my surrogate

-   Other (Specify.):

10\. If I need hospitalization for mental health problems, I prefer to
be admitted to the following programs/facilities \[Identify the reasons
for your preferences.\]:

-   Program/Facility:

-   Reason:

11\. I would prefer to NOT be admitted to the following mental health
programs/facilities \[Identify the reasons for your preferences.\]:

-   Program/Facility:

-   Reason:

-   Program/Facility:

-   Reason:

**OTHER INFORMATION AND PREFERENCES**

12\. Staff of the hospital or crisis unit can help me get my mental
health symptoms under control by doing the following:

13\. Staff can help me relax, become less agitated, and minimize the use
of restraint and seclusion by doing the following:

14\. I have the following other preferences about treatments for my
mental health problem(s):

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| Initial the       |                                                  |
| completed         |                                                  |
| worksheet and     |                                                  |
|                   |                                                  |
| attach it to your |                                                  |
| advance           |                                                  |
| directive.        |                                                  |
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| Initials:         |                                                  |
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| Date:             |                                                  |
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