(1) A supported decision-making agreement is valid if it is in writing, entered into voluntarily as described under s. 52.10, signed and dated as described under s. 52.18, and in substantially the following form: SUPPORTED DECISION-MAKING AGREEMENT APPOINTMENT OF SUPPORTER I, .... (insert name), make this agreement voluntarily and of my own free will. I agree and designate that Name of supporter .... Address of supporter .... E-mail address of supporter .... Phone number(s) of supporter .... is my supporter. For the following everyday life decisions, if I have checked “Yes,” my supporter may help me with that type of decision, but if I have checked “No,” my supporter may not help me with that type of decision: Obtaining food, clothing, and shelter — Yes.... No.... Taking care of my physical health — Yes.... No.... Managing my financial affairs — Yes.... No.... Taking care of my mental health — Yes.... No.... Applying for public benefits — Yes.... No.... Assistance with seeking vocational rehabilitation services and other vocational supports — Yes.... No.... The following are other decisions I have specifically identified that I would like assistance with .... If I have not checked either “Yes” or “No” or specifically identified and listed a decision immediately above, my supporter may not help me with that type of decision. My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may do any of the following, if I have checked “Yes”: 1. Help me access, collect, or obtain information, including records, relevant to a decision. If I have checked “Yes,” my supporter may help me access, collect, or obtain the type of information specified, including relevant records, but if I have checked “No,” or I have not checked either “Yes” or “No,” my supporter may not help me access, collect, or obtain that type of information: Medical — Yes.... No.... Psychological — Yes.... No.... Financial — Yes.... No.... Education — Yes.... No.... Treatment — Yes.... No.... Other — Yes.... No.... (If “Yes,” specify the other type(s) of information with which the supporter may assist ....) 2. Help me understand my options so I can make an informed decision. Yes.... No.... 3. Help me communicate my decision to appropriate persons. Yes.... No.... 4. Help me access appropriate personal records, including protected health information under the Health Insurance Portability and Accountability Act, the Family Educational Rights and Privacy Act, and other records that may or may not require a release for specific decisions I want to make. Yes.... No.... 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. (print) Name of person designating a supporter .... Signature .... Date .... CONSENT OF SUPPORTER I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age. I, .... (name of supporter), consent to act as a supporter under this agreement. Supporter: (print) Name .... Address .... E-mail address .... Phone number(s) .... Signature .... Date .... STATEMENT AND SIGNATURE OF WITNESSES OR SIGNATURE OF NOTARY (This agreement must be signed either by 2 witnesses who are at least 18 years of age or by a notary public.) OPTION I: WITNESSES I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age. Witness No. 1: (print) Name .... Address .... Phone number(s) .... Signature .... Date .... Witness No. 2: (print) Name .... Address .... Phone number(s) .... Signature .... Date .... OPTION II: NOTARY PUBLIC State of .... County of .... This document was acknowledged before me on .... (date), by (name of adult with a functional impairment) and ..... (name of supporter). Signature of notary .... (Seal, if any, of notary) Printed name .... My commission expires: .... (2) The department of health services shall prepare and provide access to a supported decision-making agreement instrument and accompanying information for adults with functional impairments, family members of adults with functional impairments, education professionals and school districts, health care and social service professionals, county clerks, and local bar associations. The department may charge a reasonable fee for the cost of preparation and distribution.
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