NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services

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(Examples: • authority to give me certain medications when I am behaving in a certain way • authority to hospitalize me if necessary to provide me with medications or to protect my safety or the safety of other people • authority to carry out the following emergency crisis action plan) C. Authority to waive my right to apply to the Capability <strong>and</strong> Consent Board for a review of a decision regarding my incapability to make a health care decision D. Authority to give or refuse consent to specific health care marked below: abortion electroconvulsive therapy (ECT) removal of any tissue from my body for implantation in another human body (e.g. organ donation to a relative) or for medical research experimental health care participation in a health care or medical research program treatments involving aversive stimuli Specific wishes regarding the above authorities: (Examples: • preferences for treatment <strong>and</strong> hospitalization • visitors • people to inform including what to tell my employer or family members) 12
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Page 1 and 2: Notes for Completing an Advance Dir
Page 3 and 4: you become mentally incapable of ma
Page 5 and 6: ATTACHMENT A - WISHES This schedule
Page 7 and 8: After completing this Directive:
Page 9: Personal assistance service is a se
Page 12 and 13: 5. Alternate Proxy (Optional) I app
Page 14 and 15: 11. (Optional) I have attached and
Page 18 and 19: 2. Health Care Wishes (Complete 2.1
Page 20 and 21: 3. Personal Care Wishes My wishes r

NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services

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