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Mental Health System
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Name of individual
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Birth date
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Name of person filling the form
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Mental Health System
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If Power of Attorney for Care is known, where is the information kept?
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If Public Guardian and Trustee is known, where is the information kept?
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Please provide name and contact information family member if known.
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If the "End of Life Care Directive" for the individual is known, where is it kept?
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DO NOT submit the form.  You can simply show the answers to the medical care personnel.  To get a hard copy, Right-Click at the form, choose 'Print'.  Under the destination drop-down box, you can choose a wireless printer, or 'Save as pdf', or 'Save to Google Drive'.
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