Okla. Stat. tit. 43A, § 43A-11-106

of attorney-in-fact.

A. A declaration stating the mental health treatment wishes of

the declarant executed in accordance with the provisions of this act

shall be substantially in the form provided by subsection E of this

section.

B. A declarant may designate a capable person eighteen (18)

years of age or older to act as attorney-in-fact to make mental

health treatment decisions. An alternative attorney-in-fact may

also be designated to act as attorney-in-fact if the original

attorney-in-fact is unable or unwilling to act at any time. An

appointment of an attorney-in-fact shall be substantially in the

form provided by subsection E of this section.

C. An attorney-in-fact who has accepted the appointment in

writing shall have authority to make decisions, in consultation with

the attending physician or psychologist, about mental health

treatment on behalf of the declarant only when the declarant is

certified as incapable and to require mental health treatment as

provided by Section 10 of this act.

1. These decisions shall be consistent with any wishes or

instructions the declarant has expressed in the declaration. If the

wishes or instructions of the declarant are not expressed, the

attorney-in-fact shall act in what the attorney-in-fact believes to

be in the best interest of the declarant.

2. The attorney-in-fact may consent to inpatient mental health

treatment on behalf of the declarant if so authorized in the advance

directive for mental health treatment.

D. An attorney-in-fact may withdraw by giving notice to the

declarant. If a declarant is incapable, the attorney-in-fact may

withdraw by giving notice to the named alternative attorney-in-fact

if any, and if none then to the attending physician or provider.

The attending physician or provider shall note the withdrawal of the

last named attorney-in-fact as part of the declarant's medical

record.

E. An advance directive for mental health treatment shall be

notarized and shall be in substantially the following form:

ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT

I, _____________________, being of sound mind and eighteen (18)

years of age or older, willfully and voluntarily make known my

wishes about mental health treatment, by my instructions to others

through my advance directive for mental health treatment, or by my

appointment of an attorney-in-fact, or both. I thus do hereby

declare:

I. DECLARATION FOR MENTAL HEALTH TREATMENT

If my attending physician or psychologist and another physician

or psychologist determine that my ability to receive and evaluate

information effectively or communicate decisions is impaired to such

Oklahoma Statutes - Title 43A. Mental Health Page 239

an extent that I lack the capacity to refuse or consent to mental

health treatment and that mental health treatment is necessary, I

direct my attending physician or psychologist and other health care

providers, pursuant to the Advance Directives for Mental Health

Treatment Act, to provide the mental health treatment I have

indicated below by my signature.

I understand that "mental health treatment" means convulsive

treatment, treatment with psychoactive medication, and admission to

and retention in a health care facility for a period up to twenty-

eight (28) days.

I direct the following concerning my mental health

care:___________________________________________________

________________________________________________________________

I further state that this document and the information contained

in it may be released to any requesting licensed mental health

professional.

____________________________ ___________________

Declarant's Signature Date

____________________________ ___________________

Witness 1 Date

____________________________ ___________________

Witness 2 Date

II. APPOINTMENT OF ATTORNEY-IN-FACT

If my attending physician or psychologist and another physician

or psychologist determine that my ability to receive and evaluate
health

professional.

____________________________ ___________________

Declarant's Signature Date

____________________________ ___________________

Witness 1 Date

____________________________ ___________________

Witness 2 Date

II. APPOINTMENT OF ATTORNEY-IN-FACT

If my attending physician or psychologist and another physician

or psychologist determine that my ability to receive and evaluate

information effectively or communicate decisions is impaired to such

an extent that I lack the capacity to refuse or consent to mental

health treatment and that mental health treatment is necessary, I

direct my attending physician or psychologist and other health care

providers, pursuant to the Advance Directives for Mental Health

Treatment Act, to follow the instructions of my attorney-in-fact.

I hereby appoint:

NAME _____________________________________

ADDRESS __________________________________

TELEPHONE #_______________________________

to act as my attorney-in-fact to make decisions regarding my mental

health treatment if I become incapable of giving or withholding

informed consent for that treatment.

If the person named above refuses or is unable to act on my

behalf, or if I revoke that person's authority to act as my

attorney-in-fact, I authorize the following person to act as my

attorney-in-fact:

NAME ______________________________________

ADDRESS ___________________________________

TELEPHONE #________________________________

My attorney-in-fact is authorized to make decisions which are

consistent with the wishes I have expressed in my declaration. If

Oklahoma Statutes - Title 43A. Mental Health Page 240

my wishes are not expressed, my attorney-in-fact is to act in what

he or she believes to be my best interest.

_______________________________________

(Signature of Declarant/Date)

III. CONFLICTING PROVISION

I understand that if I have completed both a declaration and

have appointed an attorney-in-fact and if there is a conflict

between my attorney-in-fact's decision and my declaration, my

declaration shall take precedence unless I indicate otherwise.

____________________ ___________ (signature)

IV. OTHER PROVISIONS

a. In the absence of my ability to give directions regarding my

mental health treatment, it is my intention that this advance

directive for mental health treatment shall be honored by my family

and physicians or psychologists as the expression of my legal right

to consent or to refuse to consent to mental health treatment.

b. This advance directive for mental health treatment shall be

in effect until it is revoked.

c. I understand that I may revoke this advance directive for

mental health treatment at any time.

d. I understand and agree that if I have any prior advance

directives for mental health treatment, and if I sign this advance

directive for mental health treatment, my prior advance directives

for mental health treatment are revoked.

e. I understand the full importance of this advance directive

for mental health treatment and I am emotionally and mentally

competent to make this advance directive for mental health

treatment.

Signed this _____ day of__________, 19 __

___________________________________

(Signature)

___________________________________

City, County and State of Residence

This advance directive was signed in my presence.

___________________________________

(Signature of Witness)

___________________________________

(Address)

___________________________________

(Signature of Witness)

___________________________________

(Address)