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(755 ILCS 43/75) Sec. 75. Form of declaration. A declaration for mental health treatment shall be in substantially the following form: DECLARATION FOR MENTAL HEALTH TREATMENT I ................., being an adult of sound mind, willfully and voluntarily make this declaration for mental health treatment to be followed if it is determined by 2 physicians or the court that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment. "Mental health treatment" means electroconvulsive treatment, treatment of mental illness with psychotropic medication, and admission to and retention in a health care facility for a period up to 17 days. I understand that I may become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder. These symptoms may include: ........................................................................ ........................................................................ PSYCHOTROPIC MEDICATIONS If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding psychotropic medications are as follows: ........ I consent to the administration of the following medications: ........................................................................ ....... I do not consent to the administration of the following medications: ------------------------------------------------------------------------ Conditions or limitations:.............................................. ........................................................................ ........................................................................ ELECTROCONVULSIVE TREATMENT If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding electroconvulsive treatment are as follows: ........ I consent to the administration of electroconvulsive treatment. ........ I do not consent to the administration of electroconvulsive treatment. Conditions or limitations:.............................................. ........................................................................ ........................................................................ ADMISSION TO AND RETENTION IN FACILITY If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding admission to and retention in a health care facility for mental health treatment are as follows: .......... I consent to being admitted to a health care facility for mental health treatment. ......... I do not consent to being admitted to a health care facility for mental health treatment. This directive cannot, by law, provide consent to retain me in a facility for more than 17 days. Conditions or limitations:.............................................. ........................................................................ ........................................................................ SELECTION OF PHYSICIAN (OPTIONAL) If it becomes necessary to determine if I have become incapable of giving or withholding informed consent for mental health treatment, I choose Dr. .......... ............. of ................... to be one of the 2 physicians who will determine whether I am incapable. If that physician is unavailable, that physician's designee shall determine whether I am incapable. ADDITIONAL REFERENCES OR INSTRUCTIONS ........................................................................ ........................................................................ ........................................................................ Conditions or limitations:.............................................. ........................................................................ |
| Model legislation for an Advanced Directive regarding future mental health treatment from Illinois |
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