Behavioral Health Order Form

The Behavioral Health Order Form, also known as Psychiatric Advance Directive (or PAD), is a legal document outlining an individual’s behavioral health treatment medication, and alternative treatment decisions, preferences, and history in the event that the individual lacks decisional capacity to provide consent to, withdraw from, or refuse treatment or medication. The form allows for a primary agent and alternate agent to be assigned by the individual. Individuals have to be 18 years of age and older to complete a Behavioral Health Order from. 

The form can be amended or revoked at any time. To amend or revoke the form a new Behavioral Health Order form needs to be completed signed and dated by the individual and agent(s) (if applicable) as well as witnessed by two disinterested witnesses. Note that the Agent’s signature is NOT required for an amendment to be valid if the individual is amending the form to remove the Agent. The form is effective for two years from the date signed. Unless the form is amended, the originally executed form becomes ineffective.


Information Needed

Before you start completing a PAD, ensure you have the following information available.

The individual's:

Full Name

Date of Birth


Hair and Eye Color(s)

Race and Ethnicity

The individual's behavioral health information:

Primary behavioral health diagnosis and date of diagnosis

Other mental health diagnoses, if any

Substance use condition(s)

Types of beliefs and behaviors when the behavioral health condition(s) are not well managed

Actions that make the individual feel safe and calm

Actions that make the individual feel unsafe and distressed

Contact information, including name and phone number for:

Primary Health Care Provider

Health Care Organization(s)

Agent’s and alternate agent’s (optional):

Full Name


Phone Number(s)


Best Practices

To make sure that you get the most benefit from a PAD, follow these tips from our experts.

The form needs to be signed by the individual, agent (if applicable), and 2 disinterested witnesses.

Discuss your desired medical treatment at end-of-life with your agent, alternates, doctor, religious leader, or any other person in your life that is part of your support circle.


Who to Notify

To ensure that your wishes are followed and the PAD is acknowledged, make sure you give copies to the following individuals.

Give Copies of Form to:


Alternate agents, if any



Download a Behavioral Health Order Form

More Advance Directives

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Representative Payee


Medical Power of Attorney


Behavioral Health Order Form