The following declaration should be signed and witnessed by a notary public, clergyman, attorney or at least by a trusted friend or reliable family member. Make several copies of the signed document and keep the original in a safe place. Give one copy to each of the persons named below (see pg. 2, item #6). Provide a copy to your attorney, if you have one.

Should you be in a position where you are subject to unwanted psychiatric treatment and/or hospitalization, ensure that the person(s) attempting such are shown and are aware of this signed and witnessed declaration. Immediately let your attorney and all other persons in your confidence know so that they may come to your aid.

Such things as apparent or undetected physical illnesses, diseases and deficiencies can manifest in mental or behavioral symptoms which can be mistaken by emergency medical personal, hospital staff and others as “psychiatric” illness. For this reason, during any attempt at involuntary hospitalization or psychiatric treatment by another, repeatedly declare your desire for a clarification of your condition of physical health. Explain that you wish to have this declaration abided by, however, do not physically resist or become aggressive. Demand to see an attorney.

A copy of your signed declaration should also be sent to the local or international branch of Citizens Commission on Human Rights^® (CCHR^®). The International address is: CCHR, 6616 Sunset Blvd., Los Angeles, California, United States, 90028.

Psychiatric Living Will

(Advance Protective Directive)

I, ______________________, born on ______________________
in ______________________________________________________
address ________________________________________________,
being of sound mind, willfully and voluntarily make known the following:

1. Under no circumstances should I be subjected to psychiatric hospitalization or psychiatric treatments or procedures including but not limited to the following:
   • Psychotropic drugs (substances which exert a mind-altering effect, including but not limited to antidepressants, antipsychotics, benzodiazepines, mood stabilizers and tranquilizers);
   • Psychosurgical or neurological operation such as lobotomy or leucotomy;
   • Convulsive treatments such as electroconvulsive therapy (also known as electroshock, shock treatment or ECT) and insulin shock;
   • Deep sleep treatment (narcosis, narcosynthesis, sleep therapy, prolonged narcosis, modified narcosis or neuroleptization);
2. I maintain my right not to have any psychiatric evaluation or diagnosis based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM) as such diagnoses are unreliable. According to Allen Frances, who was chairman of the fourth edition of DSM, “There are no objective tests in psychiatry—no X-ray, laboratory, or exam finding that says definitely that someone does or does not have a mental disorder.” (“Psychiatric Fads and Overdiagnosis,” Psychology Today, 2 June 2010.) Additionally, the DSM system is not scientific. It’s own editors state that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.” (DSM-IV, pg. xxii)
   Such codes and descriptions should not be entered into my medical records as this unreliable and unscientific information will remain in my records and may wrongly influence any future medical treatment I might receive.
3. Involuntary hospitalization or commitment is a violation of my civil rights under U.S. Code, Title 42, Chapter 21 § 1983, Civil action for deprivation of rights. Lawsuits for involuntary commitment have resulted in verdicts of $1 million or more against hospitals, doctors and other agencies and personnel:
   • Lund vs. Northwest Medical Center, (Case No. Civ. 1805-95, Court of Common Pleas, Venango County, PA, June 16, 2003), jury awarded $1,100,000 million in damages.
   • Marion vs. LaFargue Case No. 00 Civ. 0840, 2004 WL 330239, U.S. District Court for the Southern District of New York, February 23, 2004), jury verdict of $1,000,001 in damages.
   • Dick vs. Watonwan County (Case No. Civ. 4-82-1.16, U.S. District Court, District of Minnesota, April 11, 1983), more than $1 million in damages awarded to plaintiff.
4. The above directions apply in all cases, including any instance where:
   • It is claimed that my capacity or ability to give instructions may be impaired;
   • I am in a state of unconsciousness;
   • It is impossible in an actual and legal sense for me to communicate or;
   • Any physician, psychiatrist, psychologist, mental health practitioner or law enforcement official or person asserts that the matter is a “life-saving” situation requiring emergency intervention and/or treatment under any involuntary commitment law or similar legal authority.
5. In the absence of my ability to give further directions regarding the above, it is my intention that this declaration be honored by my family and physician(s) as an expression of my legal right to refuse medical, psychiatric or surgical treatment although this statement concerns only psychiatric treatment.
6. The individuals listed below are appointed and authorized to enforce this declaration of intention. Should this declaration be violated, they have my permission to initiate whatever criminal and/or civil procedures are necessary to rectify such a violation:

By this declaration, I release all medical doctors and their organizations as well as therapists from their professional discretion or confidentiality towards provision of information to the above named attorney(s) and other person(s).

This declaration is also binding for my lawful agents, guardians, family, executors or any person with the legal or other right to take care of me or my affairs.