{"data":{"id":"us-ky/krs-202a.430","jurisdiction":"us-ky","citation":"KRS 202A.430","heading":"Form of advance directive for mental health treatment.","body":"An advance directive for mental health treatment shall be in substantially the following\nform:\n\"Advance directive for mental health treatment\nI, ___________, willfully and voluntarily execute this advance directive for mental health\ntreatment. I want the i nstructions in this advance directive to be followed as described\nbelow.\nDesignated surrogate\n___I am naming a surrogate to see that my instructions for mental health treatment are\ncarried out.\n___I am not naming a surrogate to see that my instructions for mental health treatment are\ncarried out.\nI designate ____________ to act as my surrogate. If this person withdraws or is unwilling\nto act on my behalf, or if I revoke that person's authority to act as my surrogate, I\ndesignate ____________ to act as my alternate surrogate.\nIf I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are\nunwilling to act on my behalf, or if I revoke their authority to act, then the health\ncare provider and health care facility may proceed to render treatment in accordance\nwith my instructions as described here and in accordance with standards for mental\nand physical health care.\nThe person acting as my surrogate is authorized to act in accordance with the content of\nthis advance directive and may override the advance directive if, and only if, there is\nsubstantial medical evidence that failing to do so would result in harm to me. If my\ninstructions and preferences are not stated in the advance directive, the surrogate\nmay act in good faith in making treatment decisions in the manner in which the\nsurrogate believes I would act.\nPsychotropic medication provisions\nI may indicate below any refusals of treatment with specific psychotropic medications,\nnot to include an entire class of medications, due to f actors that may include but are\nnot limited to lack of efficacy, known drug sensitivity, or experience of adverse\nreaction:\nI specifically do not consent and do not authorize my surrogate to consent to the\nadministration of the following medications or the ir respective brand -name or\ngeneric equivalents for the reasons given:\nSpecific psychotropic medication   Reason for refusal\n___________________________________________________________________\n___________________________________________________________________\n___________________________________________________________________\n___________________________________________________________________\nI may list below any specific psychotropic medicati ons that I would be willing to\nhave administered to me if additional medications become necessary:\nSpecific psychotropic medications\n____________________________\n____________________________\n____________________________\n____________________________\nElectroconvulsive therapy provisions\nBelow are my instructions regarding electroconvulsive therapy (ECT):\n____I consent to electroconvulsive therapy (ECT) if it is deemed clinically appropriate to\ntreat my condition.\n____I do not consent to electroconvulsive therapy (ECT).\nPreferred procedures for emergency interventions\nI may state preferences for procedures for emergency interventions to be used when\nnecessary for my protection or the protection of others. I understand that I am\nrequesting consideration of my pr eferences for procedures for emergency\ninterventions but that my surrogate, my health care provider, and the health care\nfacility where I am a patient are not subject to civil liability for not abiding by these\npreferences. I understand that in the case of  possible harm to myself or others, my\nhealth care provider or the health care facility may need to use procedures that\noverride my stated preferences. If during an admission or while a patient in a health\ncare facility, it is determined that I am engaging in behavior that requires emergency\nintervention, my preferences regarding the procedures to be used during an\nemergency intervention and the order that I prefer the interventions to be used are as\nfollows:\nIntervention   Order of preference  Reason for this preference\nSeclusion___________________________________________________________\nPhysical restraints____________________________________________________\nSeclusion and physical\nrestraint combined_____________________________________________________\nMedication by injection_________________________________________________\nMedication in pill form_________________________________________________\nLiquid medication_____________________________________________________\nOther:_______________________________________________________________\nSigned this ____ day of _________, 20__\nSignature of grantor:_________________________\nAddress of grantor:_____________________________________________________\n_____________________________________________________________________\nIn my presence, the grantor voluntarily dated and signed this writing or directed it to\nbe dated and signed. I am not the grantor's current health care provider, a relative of the\ncurrent health care provider, o r an owner, operator, employee or relative of an owner or\noperator of a health facility in which the grantor is a client or resident.\nSignatures of witnesses: _________________________________________________\n_____________________________________________________________________\nSurrogate contact information (if designated):\nName:_______________________________\nAddress:______________________________\n_____________________________________\nTelephone:_____________________________\nSigned this ____ day of _________, 20__\nSignature of surrogate:____________________\nAlternate surrogate contact information (if designated):\nName:_______________________________\nAddress:______________________________\n_____________________________________\nTelephone_____________________________\nSigned this ____ day of _________, 20__\nSignature of alternate surrogate:______________________\"","path":["KRS Chapter 202A"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=7506","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:00Z","sha256":"9c209c2128b48526c1ae403090c48ebb7e85214b0aa3b3ac6ed47ef730021515","source_id":"us-ky","stale":false,"prev":"us-ky/krs-202a.428","next":"us-ky/krs-202a.432"},"notice":"GroundRules: Original legal text. Not legal advice."}