Author: Lucie V. Twigg

Advance Statement
Name: …………………………………………
Date: .……………………………………

Designed and Produced by the Involvement, Recovery and Wellness Centre

This is the advanced statement for:
Name:
Address:
Date of birth:
Current Medications:
Known Allergies:
If I experience a physical health illness or mental health crisis, I would like the following statement to guide my care and treatment.
Signature:

	Name:	Telephone number:
Emergency Contact:
GP:
Care Coordinator

About me
What am I like when I am feeling well?

History and symptoms of my illness

Things that trigger me to become unwell:

Symptoms that show I am in crisis and need others to take responsibility for my care, keep me safe and make decisions on my behalf: (i.e. if I become a danger to myself or others)

Where would I like to be when I am in a crisis and why this is best for me: (e.g. stay at home with support of the Home Treatment Team, admission to hospital, stay with family)

Who to contact in an emergency: (e.g. if I am admitted to hospital)

Name:	Telephone number:

My supporters:

Name:	Relationship to me:	Telephone number:

I would like the following person to act as an advocate for staff to consult if I am unwell

People I do not want to be involved in my care if I am in a crisis

Name:	Why I do not want them involved: (Optional)

Who I would like to co-ordinate my supporters: (i.e. communicating my health issues and reminding them what I would like them to do)

My wishes about the people I care for are:

My wishes about pets are:

My wishes about my home are:

Who I would like to go through my finances/bills/mail:

If I am admitted to hospital:
Personal items I would want to have with me:

Things I like doing whilst in hospital that make me feel better and help me recover: (i.e. interests and activities)

Things that have worked well for me in the past: (i.e. certain treatments or medications

What has not worked well for me in the past: (i.e. mixed wards, certain medications or treatments)

Physical problems and health conditions:

Problem: (e.g. diabetes)	What I need because of this problem: (e.g. no sugar in diet

Food and Dietary needs:

Religious and cultural needs:

Other things people should know about me:(i.e. pet hates)

I would like the following person to accompany me from hospital and help me sort my home out:

What people can do to help me on my return home: (i.e. daily activities and maintenance

When people should stop using this advance statement
How you can tell when I am able to take responsibility for myself again and you can stop using this plan:

I developed this plan in accordance with my wishes on (date):
With the help of: (list who helped you to develop your plan—if there was anyone)
If I become incapable of expressing my choices due to mental health problems, I want this document to be referred to as an expression of my choices.
Any plan with a more recent date on it replaces this one.
Signed: (your signature)
Date:
Witnessed by: (name and signature)
Lasting power of attorney: (if you have one)
Name:
Telephone number:
Copies of this advanced statement have been sent to:

Notes

Ⓒ Copyright CWP NHS Foundation Trust (DATE)