(A.R.S. §36-3286)

The MENTAL HEALTH CARE POWER OF ATTORNEY can be made by an adult of sound mind and body, voluntarily as the individual’s [PRINCIPAL’S] declaration of mental health treatment he or she is authorizing.

A PRINCIPAL can declare that they want this mental health care power of attorney to be followed if he or she is incapable, as defined by Arizona Statute 36-3281 to make competent mental health care decisions for his or her self.

The PRINCIPAL may give to their AGENT without limitation the power to make all mental health care decisions including, without limitation, full power to give or refuse consent to all medical care related to his or her my mental health condition.

There should be a provision for an alternate or successor AGENT in the event the currently appointed AGENT for any reason in the future was unable to serve or was unwilling to serve or to continue to serve.

There should be a provision that the AGENT to make decisions for the PRINCIPAL’s mental health care treatment that are consistent with the wishes of the PRINCIPAL and as expressed in the mental health care power agreement if not specifically addressed to the PRINCIPAL or otherwise known to the AGENT..

There should be language within the power agreement that if the wishes are unknown to the AGENT that the PRINCIPAL wants the AGENT to make decisions regarding the mental health care that are consistent with what the AGENT in good faith believes to be in my best interests of the PRINCIPAL.

It may provide an option for authorization of the AGENT to receive information regarding proposed mental health treatment and to receive, review, and consent to disclosure of any medical records relating to the treatment of the PRINCIPAL.

The document should provide an opportunity for the PRINCIPAL to declare and state wishes regarding mental health care treatment including medications, admission to and retention in a health care facility for mental health treatment, and outpatient services. Those options should be narrative with a place for the PRINCIPAL to initial.

This document should indicate if it is revocable or irrevocable.

The document should allow the PRINCIPAL to reject specific mental health treatment should the PRINCIPAL becomes incapable to make such decisions.

The document should have a provision for the election of or the non- election of being admitted as an inpatient or partial psychiatric hospitalization program.

The document should contain specific information concerning the PRINCIPAL as to health history to include mental or physical health history, dietary requirements, religious concerns, people to notify and any other matters that the PRINCIPAL believes are important.

Statutory language should be contained in the document so those who rely upon the mental health care power of attorney can rely upon the language, the effective date and provisions for revocation.

The PRINCIPAL must sign the document.

The name, address and telephone number of the current AGENT and any Back-up Agent should be contained in the document.

The document should contain an Affirmation of witnesses: [example below]

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.

Two witnesses should sign the Affirmations and date their signatures.

An acceptance of appointment by the AGENT is optional and will express the AGENT’S understanding of his or her role as AGENT.

Acceptance of appointment as agent: (Optional) An example of such affirmations is as follows:

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 A.R.S. §36-3281

The AGENT should date and sign the affirmation.