Positive psychiatric advance directive

of......................................

Since I believe in the existence of a mental illness, which could become acute with me, and/or which is possibly even genetically assessed in me, I would like to use my civil liberty to establish hereby a positive psychiatric advance directive in order to protect me against the consequences of this possible illness, by limiting my civil rights in the following points:

(one or more denominations possible)

o If the following psychiatrist/psychiatry hospital/socialpsychiatric service: 

.......................................................................................................................................... (Name and address)

o If a physician

should determine a mental illness with me, I hereby authorizes them that they take care over my further treatment, thus I fast again recover. I authorize them to use in their documentations typically slanderous words such as schizophrenic, manic depressive, borderline etc. and to pass on in writing to state institutions and/or insurance companies.

In particular I relieve them hereby of the risk of a later accusation of bodily harm and unlawful detention, as well as I authorize them hereby to the following actions:

o  Compulsory hospitalization into a closed ward of

.........................................................................................................................................Psychiatric Hospital

o commitment into a locked ward of a psychiatry of their choice

o forced treatment with the following medicines 

..........................................................................................................................................

o Forced treatment with medicines according to free medical discretion, however the rules of their art

o The necessary coercion may be executed also by physical force and four point restraint of my body to the bed according to medical discretion, I want the following proceeding:

..........................................................................................................................................

o The forced treatment is to be achieved by each physical force and adjustment necessary according to  medical discretion.

This Advance directive can be recalled by a new written statement at any time, if I were not declared being mentlly ill at the time of this new statement according to the advance directive stated above. 

Place, date, signature...........................................................................................................................

This Advance directive I handed out to the following persons of confidence for keeping and use it, and they shall be immediately informed in case I sign new advance directive:

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