§ 42-66.13-10. Form of supported decision-making agreement. A supported decision-making agreement may be in any form not inconsistent with the following form and the other requirements of this chapter. Use of the following form is presumed to meet statutory provisions.

SUPPORTED DECISION-MAKING AGREEMENT

Appointment of Supporter

I, ............................................................ (insert your name), make this agreement of my own free will.

I agree and designate that:

Name: .............................................

Address: .............................................

Phone Number: .............................................

E-mail Address: .............................................

is my supporter. My supporter may help me with making everyday life decisions relating to the following:

Y/N Obtaining food, clothing, and shelter

Y/N Taking care of my health

Y/N Other (specify):

I agree and designate that:

Name: .............................................

Address: .............................................

Phone Number: .............................................

E-mail Address: .............................................

is my supporter. My supporter may help me with making everyday life decisions relating to the following:

Y/N Obtaining food, clothing, and shelter

Y/N Taking care of my physical health

Y/N Other (specify):

My supporter(s) is (are) not allowed to make decisions for me. To help me with my decisions, my supporter(s) may:

(1) Help me access, collect, or obtain information that is relevant to a decision, including medical, psychological, educational, or treatment records;

(2) Help me gather and complete appropriate authorizations and releases;

(3) Help me understand my options so I can make an informed decision; and

(4) Help me communicate my decision to appropriate persons.

Effective Date of Supported Decision-Making Agreement

This supported decision-making agreement is effective immediately and will continue until ............................................. (insert date) or until the agreement is terminated by my supporter or me or by operation of law.

Signed this .................. day of .................., 20 ............

Consent of Supporter

I, ............................................................ (name of supporter), consent to act as a supporter under this agreement, and acknowledge my responsibilities under chapter 66.13 of title 42.

(Signature of supporter) (Printed name of supporter)

My relationship to the principal is: .............................................

I, ............................................................ (name of supporter), consent to act as a supporter under this agreement, and acknowledge my responsibilities under chapter 66.13 of title 42.

(Signature of supporter) (Printed name of supporter)

My relationship to the principal is: .............................................

Consent of the Principal

(My signature) (My printed name)

Witnesses or Notary

(Witness 1 signature) (Printed name of witness 1)

(Witness 2 signature) (Printed name of witness 2)

Or

State of .............................................

County of .............................................

This document was acknowledged before me on (date) by

.............................................

(Signature of notarial officer)

(Seal, if any, of notary)

.............................................

(Printed name)

My commission expires: .............................................

History of Section. (P.L. 2019, ch. 113, § 1; P.L. 2019, ch. 124, § 1.)