Vermont Advance Directive
for Health Care
Prepared by the Vermont Ethics Network, July 2011
Explanation & Instructions
You have the right to:
1. Name someone else to make health care decisions for you when or if you are unable to make them
2. Give instructions about what types of health care you want or do not want.
It is important to talk with those people closest to you and with your health care providers about your goals,
wishes and preferences for treatment.
You may use this form in its entirety or you may use any part of it. For example, if you only want to choose an
agent in Part One, you may fill out just that section and then go to Part Five to sign in the presence of appropriate witnesses.
You are free to use another form so long as it is properly witnessed. More detailed forms providing greater
options and information regarding mental health care preference can be found on the VEN website at
Part ONE of this form allows you to name a per