Okla. Stat. tit. 43A § 11-106
ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT
I, _____________________, being of sound mind and eighteen (18) years of age or older, willfully and voluntarily make known my wishes about mental health treatment, by my instructions to others through my advance directive for mental health treatment, or by my appointment of an attorney-in-fact, or both. I thus do hereby declare:
If my attending physician or psychologist and another physician or psychologist determine that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment and that mental health treatment is necessary, I direct my attending physician or psychologist and other health care providers, pursuant to the Advance Directives for Mental Health Treatment Act, to provide the mental health treatment I have indicated below by my signature.
I understand that "mental health treatment" means convulsive treatment, treatment with psychoactive medication, and admission to and retention in a health care facility for a period up to twenty-eight (28) days.
I direct the following concerning my mental health care:___________________________________________________
________________________________________________________________
I further state that this document and the information contained in it may be released to any requesting licensed mental health professional.
____________________________ ___________________Declarant's Signature Date
____________________________ ___________________Witness 1 Date
____________________________ ___________________Witness 2 Date
If my attending physician or psychologist and another physician or psychologist determine that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment and that mental health treatment is necessary, I direct my attending physician or psychologist and other health care providers, pursuant to the Advance Directives for Mental Health Treatment Act, to follow the instructions of my attorney-in-fact.
I hereby appoint:
NAME _____________________________________
ADDRESS __________________________________
TELEPHONE #_______________________________ to act as my attorney-in-fact to make decisions regarding my mental health treatment if I become incapable of giving or withholding informed consent for that treatment.
If the person named above refuses or is unable to act on my behalf, or if I revoke that person's authority to act as my attorney-in-fact, I authorize the following person to act as my attorney-in-fact:
NAME ______________________________________
ADDRESS ___________________________________
TELEPHONE #________________________________
My attorney-in-fact is authorized to make decisions which are consistent with the wishes I have expressed in my declaration. If my wishes are not expressed, my attorney-in-fact is to act in what he or she believes to be my best interest.
____________________ ___________ (signature)
I understand that if I have completed both a declaration and have appointed an attorney-in-fact and if there is a conflict between my attorney-in-fact's decision and my declaration, my declaration shall take precedence unless I indicate otherwise.
_______________________________(signature)
Signed this _____day of__________, 19 __
____________________________
(Signature)
____________________________
City, County and State of Residence This advance directive was signed in my presence.
____________________________
(Signature of Witness)
____________________________
(Address)
____________________________
(Signature of Witness)
____________________________
(Address)
Okla. Stat. tit. 43A, § 11-106