Name: ________________________________________________________ DOB: __________________

Address: ______________________________________________________________________________

____________________________________________________________________________________

I, the undersigned, being of sound mind, willfully and voluntarily make the following declaration:

1. Refusal of Psychiatric Treatment:
I do not consent to any contact with a psychiatrist, psychologist or other mental health worker, psychiatric hospitalization or treatment, including but not limited to:

• Psychotropic drugs (e.g., antidepressants, antipsychotics, benzodiazepines, tranquilizers, stimulants, psychedelics, etc.;

• Psychosurgery in any form, including brain-intervention stimulation

• Convulsive therapies (e.g., electroconvulsive therapy/ECT, insulin shock);

• Deep sleep treatment (narcosis, prolonged sedation).

2. No Psychiatric Evaluation or Diagnosis:
I do not consent to psychiatric evaluations, including those based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) or equivalent manual, as such diagnoses are unreliable, are not based on any physical-scientific test, and should not be entered into my medical records.

3. Protection of Civil Rights:
Involuntary psychiatric commitment violates my rights. I request full physical medical evaluation to rule out undetected physical illness that may appear as “psychiatric.”

4. Applicability in All Circumstances:
This directive applies even if I am unconscious, deemed “incapacitated,” or if someone claims emergency grounds under any involuntary commitment law. It remains valid regardless of my ability to communicate.

5. Intent and Legal Force:
This document is a formal expression of my right to refuse psychiatric intervention. It is to be respected by all physicians, mental health professionals, and law enforcement.

6. Authorized Advocates:
The following persons are appointed to act on my behalf, enforce this directive, and take legal action if it is violated:

Name:___________________________________ Address: ______________________________________________________

Name:___________________________________ Address: ______________________________________________________

Name:___________________________________ Address: ______________________________________________________

Instructions:

• Sign and have this witnessed by a notary public, attorney, clergyman, or trusted individual.

• Distribute copies to your listed advocates, your attorney (if applicable), and send one to Citizens Commission on Human Rights International, 6616 Sunset Blvd., Los Angeles, CA 90028

• Keep the original in a secure place. Present this document if faced with unwanted psychiatric intervention. Remain calm, request medical clarification, and ask to speak to an attorney.

Signed: __________________________________________________________ Date:______________________

Print Name:______________________________________________________

Witness Signature:_____________________________________________ Date:______________________

Printed Witness Name:___________________________________________

Witness Contact Information: ________________________________________________________________