Nottinghamshire Healthcare
NHS
NHS Trust
positive about mental health and learning disability
advance statement
Name: ........................................................................Date ......................
2
1).
2).
What am I like
when I am feeling well?
Syptoms that show I am in crisis and need others
to take responsibility for my care,
keep me safe and make decisions on my behalf:
ADVANCE STATEMENT
3
3). My
Name:
4
supporters
Their connection to me
(e.g. friend, relative,
social worker):
Telephone
and/or
email:
The people I would like mental health services to contact
in an emergency (e.g. if I am admitted to hospital):
Name:
Telephone and/or email:
The person I would like to co-ordinate my supporters:
(by telling them I am in crisis, reminding them what I would like them
to do, arranging for someone else to do it if they are not able to)
Name:
Telephone and/or email:
How I would like disputes between my supporters to be resolved:
ADVANCE STATEMENT
5
People I do not want to be involved if I am in crisis:
Name:
6
Why I do not want
them involved: (optional)
4). Things
to take care of
Things I want my supporters to take care of when I am in crisis:
(e.g. feeding pets, looking after bills, telling others that I am unwell)
Name:
What I would like this person to
take care of while I am in crisis:
ADVANCE STATEMENT
7
5). Medication
Name:
My
Psychiatrist:
My Care
Co-ordinator:
My GP:
Current
medication:
(please list)
8
Telephone:
Medications, or additional medications,
I would prefer to take in a crisis:
Type of medication:
Reasons I would prefer to take it:
Medication that would be acceptable to me
but I would prefer to avoid if possible:
Type of medication:
Reasons I would prefer not to take it:
Medication I DO NOT want to take:
Type of medication:
Reasons I do not want to take it:
Known allergies to medication: (please list)
ADVANCE STATEMENT
9
6). Other
treatments and help
Other treaments I am currently receiving:
(e.g. talking therapy, self-help group – please list)
Other treatments and help I would like while I am in crisis:
Type of treatment/help:
Reasons I would like it:
Other treatments and help I DO NOT want:
Type of treatment/help:
10
Reasons why I DO NOT want it:
7). Where
would I like to be
when I am in crisis
First preference: (e.g. stay at home with the Home Treatment
Team visiting, stay with my mother, admission to hospital)
Where:
Why I would prefer this:
Second preference: (if first preference is not possible)
Where:
Why I would prefer this:
Third preference: (if second preference is not possible)
Where:
Why I would prefer this:
ADVANCE STATEMENT
11
If I have to be admitted to hospital I would prefer to go to:
(give the name of your preferred ward, hospital or type of ward,
e.g. a single sex ward)
Ward/hospital:
Why I would prefer to go there:
If I have to be admitted to hospital I would prefer NOT to:
go to (give the name of your non-preferred ward, hospital or
type of ward, e.g. a single sex ward)
Ward/hospital:
12
Why I would prefer NOT to go there:
8).
How I would like to be helped
What people can do that is helpful to me
when I am in crisis: (please list)
What I DO NOT find helpful:
(please list and give reasons)
ADVANCE STATEMENT
13
9). Special
needs
Physical problems and health conditions:
Problem (e.g. hearing
difficulties, diabetes):
What I need because of this problem
(e.g. information in written form,
no sugar in diet):
Religious and cultural needs:
Food and dietary needs:
14
Things I want to have with me if I am admitted to hospital:
(e.g. a photo of my children, my diary, my glasses)
Pet hates and other things people should know about me:
(e.g. I hate people calling me “dear”, I am grumpy in the morning)
Other special needs:
ADVANCE STATEMENT
15
When people should stop
using this advance statement
10).
How you can tell when I am able to take
responsibility for myself again and you can
stop using this plan:
16
11). If
I am in danger
If my behaviour becomes a danger to myself or to other
people I would like my supporters to:
(please describe what you would like them to do)
ADVANCE STATEMENT
17
12). About
my plan
I developed this plan on (date):
with the help of:
(list who helped you to develop your plan – if there was anyone)
Any plan with a more recent date on it replaces this one.
Signed: (your signature)
Date:
Witnessed by:
Name:
18
Signature:
Date:
Lasting Power of Attorney: (if you have one)
Name:
Telephone:
Notes:
ADVANCE STATEMENT
19
Notes:
20
Notes:
ADVANCE STATEMENT
21
Notes:
22
Notes:
ADVANCE STATEMENT
23
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© 2008 South West London and
St George’s Mental Health NHS Trust
All rights reserved.
Nottinghamshire Healthcare NHS Trust
The Resource
Duncan MacMillan Close
Porchester Road
Nottingham NG3 6AA
For further information about this document please
contact Julie Repper, [email protected]
Illustration: ‘Picnic at Chatsworth’ used courtesy of Rob Van Beek
Nottinghamshire Healthcare
NHS
NHS Trust
positive about mental health and learning disability