Arizona Mental Health Care Power of Attorney (POA)
This document allows you to legally appoint someone to make mental health treatment decisions for you in case you become incapable of giving informed consent. It covers decisions like psychiatric hospital admission, medications, and access to mental health records.
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📄 Download the Full Arizona Life Care Planning Packet (PDF)
❓ What Is This Form For?
This form is different from a general health care power of attorney. It is specifically designed for:
People who may face serious mental health challenges
Anyone wanting to plan ahead in case of psychiatric hospitalization or treatment
Ensuring you receive—or don’t receive—specific kinds of mental health care
It only takes effect if you are determined to be incapable by a licensed psychiatrist, psychologist, or neurologist in Arizona.
📝 Step-by-Step Instructions
Section 1: Your Information (the “Principal”)
What it asks:
Full legal name
Date of birth
Address
Phone number and email
Helpful Tip: Use accurate and current contact details so providers can identify your document.
Section 2: Appointing Your Mental Health Care Agent
What it asks:
Name and contact information for your primary agent
Optionally, name a backup (alternate) agent
Helpful Tip: Choose someone you trust to understand and advocate for your values around mental health care. Talk with them before listing them.
Section 3: What Your Agent Can Do
You can initial or mark which mental health treatments your agent is authorized to approve:
📄 Access to your mental health records
💊 Consent to psychiatric medications
🏥 Admission to inpatient or partial hospitalization programs
✍️ Other custom instructions (optional)
Helpful Tip: You don’t need to select all options. Only initial the powers you’re comfortable giving your agent.
Section 4: Treatments You Do NOT Want
What it asks: You can write down specific treatments you do not want your agent to approve—like electroconvulsive therapy, certain medications, or hospitalization.
Helpful Tip: Write “None” if you have no restrictions. Be clear and specific if you want to limit certain types of care.
Section 5: Revoking This Form
You can revoke this form at any time you are considered capable of making decisions. However, during periods of incapacity, the form remains active and cannot be revoked.
Section 6: HIPAA Waiver
You may initial to allow your agent to access your protected mental health records under federal HIPAA laws.
Helpful Tip: Initialing this gives your agent the information they need to help make informed care decisions on your behalf.
✍️ Signature and Verification
You must sign this form in front of either a notary public OR one adult witness (but not both).
Witness/Notary must NOT be:
Under 18
Related to you
Named as your agent
Entitled to any part of your estate
Your health care provider
✔️ Final Steps
Sign in front of a witness or notary Ensure they meet the legal qualifications.
Make copies Give to your agent, mental health providers, and include in any care or hospital file.
Keep it accessible Place it in a known location with your other advance directives.
Register it (optional) Submit a copy to the Arizona Healthcare Directives Registry for digital access by providers.
🛠️ Need Help?
We can walk you through this form, coordinate notarization or witnessing, and help ensure your mental health care choices are honored with compassion and clarity.
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