ACCEPTANCE OF APPOINTMENT

The undersigned hereby accepts appointment to and agrees to perform the duties of the agent for mental health treatment for (Principal) , the principal. In accepting this appointment I understand that I will not be subject to criminal prosecution, civil liability or professional disciplinary action for an action taken in good faith under the Declaration for Mental Health Treatment. I also understand that as a result of acting in the capacity of agent, I will not be personally liable for the cost of treatment provided to the principal. I may withdraw as agent by giving notice to the principal or, if the principal is incapable, by giving notice to the attending physician or the mental health service provider.

I declare that I am not the attending physician, mental health service provider, or an employee of the physician or provider, who is not related to the principal by blood, marriage or adoption nor am I an owner, operator or employee of a health care facility in which the principal is a patient or resident who is not related to the principal by blood, marriage or adoption.

Dated this          day of                              , 19   .

Signature:                                                                

Print name:                                                              

Residence:                                                               

                                                                               

Phone #: