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
Gender
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
Address
Phone Number(s)
Signature
Best Practices
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
Give Copies of Form to:
Agent
Alternate agents, if any
Doctor
Therapist
Download a Behavioral Health Order Form
More Advance Directives
Financial Power of Attorney
Medical Orders for Scope of Treatment
Representative Payee
Medical Power of Attorney
Behavioral Health Order Form