2005 Idaho Code - 66-613 — FORM OF DECLARATION

                                  TITLE  66
                        STATE CHARITABLE INSTITUTIONS
                                  CHAPTER 6
                   DECLARATIONS FOR MENTAL HEALTH TREATMENT
    66-613.  FORM OF DECLARATION. A declaration for mental health treatment
shall contain the following language, or language that is substantially
similar.
         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:
         (1)  This document allows you to make decisions in advance about
    three (3) types of mental health treatment: psychotropic medication,
    electroconvulsive therapy, and short-term (up to seventeen (17) days)
    admission to a treatment facility. The instructions that you include
    in this declaration will be followed only if a court, two (2)
    physicians that include a psychiatrist, or a physician and a
    professional mental health clinician believe that you are incapable
    of making treatment decisions. Otherwise, you will be considered
    capable to give or withhold consent for the treatments.
         (2)  You may also appoint a person as your agent to make these
    treatment decisions for you if you become incapable. The person you
    appoint has a duty to act consistent with your desires as stated in
    this document or, if your desires are not stated or otherwise made
    known to the agent, to act in a manner consistent with what the
    person in good faith believes to be in your best interest. 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 agent at any time.
         (3)  This document will continue in effect until revoked. You
    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, TWO
    (2) PHYSICIANS THAT INCLUDE A PSYCHIATRIST, OR A PHYSICIAN AND A
    PROFESSIONAL MENTAL HEALTH CLINICIAN. A revocation is effective when
    it is communicated to your attending physician or other provider.
         (4)  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 (2)
    qualified witnesses who are personally known to you and who are
    present when you sign or acknowledge your signature.