Mental Health Declaration and Power of Attorney Form
Complete this form to declare a mental health-related status and authorize a trusted person to act on your behalf within the scope you specify.
Principal Information
Principal Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Declaration Details
Mental health declaration statement
*
Date declaration made
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Power of Attorney Authorization
Attorney-in-Fact / Authorized Person Full Name
*
First Name
Middle Name
Last Name
Relationship to the Principal
*
Scope of Authority Granted
*
Financial Matters
Health-Related Decisions
Housing / Placement Decisions
General Administrative Matters
Other
Effective Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Should be Empty: