Advance Directive Acknowledgement Form

Client Name

Date

I acknowledge that Kirstin Care OMHC (KIRSTIN CARE ) has provided me with a copy of the Maryland Department of Mental Health and Hygiene Advance Directive for Mental Health Treatment. I acknowledge that I have read and understand the notice and my rights contained within.

Yes No

I have an Advance Directive (if yes, a copy must be provided)

Yes No

I choose to decline the Advance Directive

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Client Signature

Date

Staff Signature

Date

COMAR 10.21.17.04 C

Revised 5/09/19

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