85R7451 GCB-F
By: Wray H.B. No. 1787
A BILL TO BE ENTITLED
AN ACT
relating to the execution of a declaration for mental health
treatment.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Section 137.003, Civil Practice
and Remedies Code, is amended to read as follows:
Sec. 137.003. EXECUTION AND WITNESSES; EXECUTION AND
ACKNOWLEDGMENT BEFORE NOTARY PUBLIC.
SECTION 2. Section 137.003(a), Civil Practice and Remedies
Code, is amended to read as follows:
(a) A declaration for mental health treatment must be:
(1) signed by the principal in the presence of two or
more subscribing witnesses; or
(2) signed by the principal and acknowledged before a
notary public.
SECTION 3. Section 137.011, Civil Practice and Remedies
Code, is amended to read as follows:
Sec. 137.011. FORM OF DECLARATION FOR MENTAL HEALTH
TREATMENT. The declaration for mental health treatment must be in
substantially the following form:
DECLARATION FOR MENTAL HEALTH TREATMENT
I, __________________, being an adult of sound mind, wilfully
and voluntarily make this declaration for mental health treatment
to be followed if it is determined by a court that my ability to
understand the nature and consequences of a proposed treatment,
including the benefits, risks, and alternatives to the proposed
treatment, is impaired to such an extent that I lack the capacity to
make mental health treatment decisions. "Mental health treatment"
means electroconvulsive or other convulsive treatment, treatment
of mental illness with psychoactive medication, and preferences
regarding emergency mental health treatment.
(OPTIONAL PARAGRAPH) 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:
________________________________________________________________
PSYCHOACTIVE MEDICATIONS
If I become incapable of giving or withholding informed
consent for mental health treatment, my wishes regarding
psychoactive medications are as follows:
_____ I consent to the administration of the following
medications:
________________________________________________________________
_____ I do not consent to the administration of the following
medications:
________________________________________________________________
_____ I consent to the administration of a federal Food and
Drug Administration approved medication that was only approved and
in existence after my declaration and that is considered in the same
class of psychoactive medications as stated below:
________________________________________________________________
Conditions or limitations: ________________________________
CONVULSIVE TREATMENT
If I become incapable of giving or withholding informed
consent for mental health treatment, my wishes regarding convulsive
treatment are as follows:
_____ I consent to the administration of convulsive
treatment.
_____ I do not consent to the administration of convulsive
treatment.
Conditions or limitations: ________________________________
PREFERENCES FOR EMERGENCY TREATMENT
In an emergency, I prefer the following treatment FIRST
(circle one) Restraint/Seclusion/Medication.
In an emergency, I prefer the following treatment SECOND
(circle one) Restraint/Seclusion/Medication.
In an emergency, I prefer the following treatment THIRD
(circle one) Restraint/Seclusion/Medication.
______ I prefer a male/female to administer restraint,
seclusion, and/or medications.
Options for treatment prior to use of restraint, seclusion,
and/or medications:
________________________________________________________________
Conditions or limitations: ________________________________
ADDITIONAL PREFERENCES OR INSTRUCTIONS
________________________________________________________________
Conditions or limitations: ________________________________
Signature of Principal/Date: ______________________________
SIGNATURE ACKNOWLEDGED BEFORE NOTARY PUBLIC
State of Texas
County of_________
This instrument was acknowledged before me on ______(date) by
___________(name of notary public).
_____________________
NOTARY PUBLIC, State of Texas
Printed name of Notary Public:
_____________________________
My commission expires:
_____________________________
SIGNATURE IN PRESENCE OF TWO WITNESSES
STATEMENT OF WITNESSES
I declare under penalty of perjury that the principal's name
has been represented to me by the principal, that the principal
signed or acknowledged this declaration in my presence, that I
believe the principal to be of sound mind, that the principal has
affirmed that the principal is aware of the nature of the document
and is signing it voluntarily and free from duress, that the
principal requested that I serve as witness to the principal's
execution of this document, and that I am not a provider of health
or residential care to the principal, an employee of a provider of
health or residential care to the principal, an operator of a
community health care facility providing care to the principal, or
an employee of an operator of a community health care facility
providing care to the principal.
I declare that I am not related to the principal by blood,
marriage, or adoption and that to the best of my knowledge I am not
entitled to and do not have a claim against any part of the estate of
the principal on the death of the principal under a will or by
operation of law.
Witness
Signature: ______________________________________________
Print
Name: _____________________________________________________
Date: ______________________
Address: _______________________________________________________
Witness
Signature: ______________________________________________
Print
Name: _____________________________________________________
Date: ______________________
Address: _______________________________________________________
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:
This document allows you to make decisions in advance about
mental health treatment and specifically three types of mental
health treatment: psychoactive medication, convulsive therapy,
and emergency mental health treatment. The instructions that you
include in this declaration will be followed only if a court
believes that you are incapacitated to make treatment decisions.
Otherwise, you will be considered able to give or withhold consent
for the treatments.
This document will continue in effect for a period of three
years unless you become incapacitated to participate in mental
health treatment decisions. If this occurs, the directive will
continue in effect until you are no longer incapacitated.
You have the right to revoke this document in whole or in part
at any time you have not been determined to be incapacitated. YOU
MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED BY A COURT
TO BE INCAPACITATED. A revocation is effective when it is
communicated to your attending physician or other health care
provider.
If there is anything in this document that you do not
understand, you should ask a lawyer to explain it to you. This
declaration is not valid unless it is either acknowledged before a
notary public or signed by two qualified witnesses who are
personally known to you and who are present when you sign or
acknowledge your signature.
SECTION 4. The changes in law made by this Act to Sections
137.003 and 137.011, Civil Practice and Remedies Code, apply to a
declaration for mental health treatment executed on or after the
effective date of this Act. A declaration for mental health
treatment executed before the effective date of this Act is
governed by the law as it existed on the date the declaration for
mental health treatment was executed, and the former law is
continued in effect for that purpose.
SECTION 5. This Act takes effect September 1, 2017.