2005 Washington Revised Code RCW 71.32.260: Form.

Mental Health Advance Directive

11.94 RCW) . . . . . . "Living will" (Health care directive; chapter 70.122 RCW) . . . . . . I have appointed more than one agent. I understand that the most recently appointed agent controls except as stated below: . . . . . . . . . . . .
PART VIII.

NOTIFICATION OF OTHERS AND CARE OF PERSONAL AFFAIRS (Fill out this part only if you wish to provide nontreatment instructions.) I understand the preferences and instructions in this part are NOT the responsibility of my treatment provider and that no treatment provider is required to act on them. A. Who Should Be Notified I desire my agent to notify the following individuals as soon as possible when this directive becomes effective: Name: . . . . . . . . . . . . Address: . . . . . . . . . . . . Day telephone: . . . . . . . . . . . . Evening telephone: . . . . . . . . . . . . Name: . . . . . . . . . . . . Address: . . . . . . . . . . . . Day telephone: . . . . . . . . . . . . Evening telephone: . . . . . . . . . . . . B. Preferences or Instructions About Personal Affairs I have the following preferences or instructions about my personal affairs (e.g., care of dependents, pets, household) if I am admitted to a mental health treatment facility: . . . . . . . . . . . . . . . . . . . . . . . . C. Additional Preferences and Instructions: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PART IX.

SIGNATURE      By signing here, I indicate that I understand the purpose and effect of this document and that I am giving my informed consent to the treatments and/or admission to which I have consented or authorized my agent to consent in this directive. I intend that my consent in this directive be construed as being consistent with the elements of informed consent under chapter 7.70 RCW.      Signature: . . . . . . . . . . . . Date: . . . . . . . . . . . .      Printed Name: . . . . . . . . . . . . This directive was signed and declared by the "Principal," to be his or her directive, in our presence who, at his or her request, have signed our names below as witnesses. We declare that, at the time of the creation of this instrument, the Principal is personally known to us, and, according to our best knowledge and belief, has capacity at this time and does not appear to be acting under duress, undue influence, or fraud. We further declare that none of us is:      (A) A person designated to make medical decisions on the principal's behalf;      (B) A health care provider or professional person directly involved with the provision of care to the principal at the time the directive is executed;      (C) An owner, operator, employee, or relative of an owner or operator of a health care facility or long-term care facility in which the principal is a patient or resident;      (D) A person who is related by blood, marriage, or adoption to the person, or with whom the principal has a dating relationship as defined in RCW 26.50.010;      (E) An incapacitated person;      (F) A person who would benefit financially if the principal undergoes mental health treatment; or      (G) A minor. Witness 1: Signature: . . . . . . . . . . . . Date: . . . . . . . . . . . .      Printed Name: . . . . . . . . . . . .           Telephone: . . . . . . . . . . . . Address: . . . . . . . . . . . . Witness 2: Signature: . . . . . . . . . . . . Date: . . . . . . . . . . . .      Printed Name: . . . . . . . . . . . .           Telephone: . . . . . . . . . . . . Address: . . . . . . . . . . . .
PART X.

RECORD OF DIRECTIVE I have given a copy of this directive to the following persons: . . . . . . . . . . . . . . . . . . . . . . . . DO NOT FILL OUT PART XI UNLESS YOU INTEND TO REVOKE

THIS DIRECTIVE IN PART OR IN WHOLE
PART XI.

REVOCATION OF THIS DIRECTIVE (Initial any that apply): . . . . . . I am revoking the following part(s) of this directive (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I am revoking all of this directive. By signing here, I indicate that I understand the purpose and effect of my revocation and that no person is bound by any revoked provision(s). I intend this revocation to be interpreted as if I had never completed the revoked provision(s).      Signature: . . . . . . . . . . . . Date: . . . . . . . . . . . .      Printed Name: . . . . . . . . . . . . DO NOT SIGN THIS PART UNLESS YOU INTEND TO REVOKE THIS

DIRECTIVE IN PART OR IN WHOLE

[2003 c 283 § 26.]