Personal Information
This section collects essential personal details needed to identify you and ensure that your care preferences are linked to the correct individual. It's also vital for contacting someone on your behalf if the need arises.
Please enter your full name.
What is your date of birth?
Type or select your date of birth.Could you provide an emergency contact? (Name, relationship, phone number)
Mental Health History
This section is dedicated to understanding your mental health history. Knowing about any diagnoses, treatments, or medications you have or are currently receiving helps ensure that your care preferences are well-informed and tailored to your needs.
Have you been diagnosed with any mental health conditions? Please specify.
Are there any treatments or medications you are currently undergoing?
Treatment Preferences
This section focuses on your preferences regarding treatment, especially in crisis situations. It's important to outline which methods you find most effective and any treatments you wish to avoid to guide healthcare providers in delivering care that aligns with your wishes.
In a crisis, what treatment methods do you prefer or find most effective?
Are there any treatments you would like to avoid?
Consent to Treatment
This section addresses who can make decisions about your treatment if you're unable to consent. Clarifying this helps ensure that your care aligns with your values and preferences, even when you can't communicate them yourself.
In situations where you can't give consent, who is authorized to make decisions on your behalf?
Are there any specific circumstances under which you would refuse treatment?
Hospitalization
This section helps outline your preferences in case hospitalization is necessary. Your input on preferred facilities and visitor policies can significantly impact your comfort and recovery.
Do you have a preferred hospital or facility for treatment?
What are your preferences regarding visitors during hospitalization?
Communication
This section focuses on your communication preferences, especially in crisis situations. Knowing how you prefer to be approached and any specific fears or triggers helps medical staff interact with you more effectively and compassionately.
How do you prefer medical staff to communicate with you during a crisis?
Are there any specific fears or triggers you'd like the staff to be aware of?
Daily Routine and Care
Understanding your daily routines and any dietary preferences is important to maintain a sense of normalcy and comfort in your care. This section covers aspects of your daily life that contribute to your mental wellbeing.
Are there daily routines or activities that are crucial for your mental wellbeing?
Do you have any dietary restrictions or preferences that need to be considered?
Additional Directives
This section allows you to provide any other information or directives that you feel are important for your caregivers or medical professionals to know about your mental health care preferences.
Is there anything else you would like your caregivers or medical professionals to know about your mental health care preferences?
Do you have any legal documents related to your mental health care that need to be considered (e.g., a Power of Attorney)?
Review and Confirmation
This final section is for you to review all the information provided and make any necessary changes before confirming your advance decision plan. It's important to ensure all details are accurate and reflect your current preferences.
Below is a summary of all the information you've provided. Please review each response carefully. You'll have the opportunity to make any changes before finalising your advance statement.