Declaration of Intention

I, _________________________________, born on __________________________________

in _________________________________, address __________________________________

being of sound mind, willfully and voluntarily make known my desire that should it be so considered or decided that I be subject to involuntary incarceration or hospitalization (also known as committal and certification) in a psychiatric hospital, ward, facility, home or nursing home, and/or that I be subject to psychiatric procedures including, but not limited to any form of psychosurgical neurological operation such as lobotomy or leucotomy, electro-convulsive treatment (also known as electroshock or shock treatment and ECT), psychotropic drugs (including benzodiazepines, major tranquilizers, antidepressants, barbiturates or neuroleptics generally); deep sleep treatment (narcosis, narcosynthesis, sleep therapy, prolonged narcosis, modified narcosis or neuroleptization), sterilization, insulin shock or any other physically based psychiatric or psychological treatment or practice, I direct that such incarceration, hospitalization, treatment or procedures not be imposed, committed or used on me.

I refuse contact with and treatment by any psychiatrist, psychologist or other mental health practitioner as these practices, according to my philosophic and/or religious convictions, do not adequately or properly diagnose and such diagnoses can constitute a false accusation about my behavior and/or beliefs and practices, and are stigmatizing and therefore a threat to one's reputation and physical and mental well-being. Any of their treatments, given against my expressed wish, are an intrusion upon and thus an assault on my body and constitute, in my view, criminal assault. Any involuntary hospitalization or commitment is a violation of my right to liberty and would therefore constitute a false imprisonment by all those advocating and authorizing such action, against my consent and wishes. If in the future, I am accused of a crime, then I direct that I be subject to due process accorded to the criminally accused and not subjected to psychiatric or psychological assessment, processing, profile, confinement or treatments.

Among other situations, the above directions and positions apply in any case where my capacity or ability to give instructions may be or may be claimed to be impaired, or should I be in a state of unconsciousness, or should my communication in an actual and/or legal sense be impossible, or where any 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.

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, psychological, psychiatric or surgical treatment.

The attorneys mentioned below are appointed and authorized to institute appropriate proceedings on my behalf should the above declaration be violated and have my permission herewith to proceed with whatever criminal and/or civil procedures necessary to rectify such a violation.

I herewith authorize the following person(s) with the enforcement of this declaration of intention:

___________________________________ ___________________________________

___________________________________ ___________________________________

All medical doctors and their organizations as well as therapists are expressly released from their professional discretion or confidentiality towards provision of information to the above named attorney(s).

The 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.

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Signed 	  	Date

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Address

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Signature of Notary / Justice of the Peace / attorney, etc. 	  	Name of Notary

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  at  

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Before me on this date (date notary witnessed the signature) 	  	(Place where signature is witnessed / notarized)