Name: ________________________________________________________ DOB: __________________

Address: ______________________________________________________________________________

____________________________________________________________________________________

I, the undersigned, being of sound and competent 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, mood stabilizers, psychedelics, etc.);

• Psychosurgery in any form, including brain-intervention procedures and 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 or confirmed by any physical or scientific test, and should not be entered into my medical records.

3. Protection of Civil Rights:
I object to, and do not consent to, any psychiatric evaluation or professional opinion offered to determine that I am a danger to myself or others, or to justify involuntary examination, detention, or treatment. I do not authorize such an evaluation or opinion to be used as a basis for civil commitment, an emergency hold, or forced treatment.

4. Applicability in All Circumstances:
This directive applies if I am unconscious, found incapacitated, unable to communicate, or if anyone claims emergency or involuntary-commitment grounds. It is not my consent to psychiatric evaluation, detention, or treatment.

5. Intent and Legal Force:
This is my refusal of psychiatric intervention. Family members, physicians, mental health staff, and, to the extent the law allows, law enforcement shall honor it. If another person seeks a court order for my evaluation, detention, or treatment, I direct that this document be filed and argued as my controlling instruction and that any such petition be denied as contrary to my stated wishes.

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: ________________________________________________________________